Every finding on record at North Pointe Nursing and Rehabilitation

Based on interview and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 6 residents (Resident #1) reviewed for medical records. 1.The facility failed to ensure Resident #1's medical record included documentation reflecting the resident had received showers/baths in July 2026. 2. The facility failed to ensure Resident #1's completion or refusal of prescribed wound care was accurately documented on her wound administration record (WAR) for 08/05/26. The failure placed residents at risk of not having continuity of care. Findings included: Record review of Resident #1's face sheet, dated 08/12/26, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 08/06/26.Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected her diagnoses included end stage renal disease (chronic kidney disease), peripheral vascular disease (a slow and progressive circulation disorder), and diabetes mellites (high blood sugar levels). The MDS reflected Resident #1's cognition was moderately impaired with a BIMS score of 09. The MDS Assessment Section GG - Functional Abilities did not address if resident needed moderate or maximal assistance from staff in regard to personal hygiene. The MDS further reflected that the resident was at risk of developing pressure ulcers/injuries.Record review of Resident #1's care plan, revised 07/30/26, reflected [Resident #1] has an ADL Self Care Performance Deficit. Refuses showers at times. Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Interventions: Bathing: requires staff x1 for assistance.Record review of Resident #1's ADL Record for Bathing revealed Resident #1 shower days were Tuesday, Thursday, Saturday; Q Shift: Days 6AM-2PM.Record review of Resident #1's ADL Record for July and August 2026 in the section titled Bathing reflected the following: - Type of Bath and Not Applicable was marked indicating no showers were provided. For 10 days Not Applicable was marked in July 2026 and 1 day was marked in August 2026. -Section titled PRN Bathing reflected the following: ADL - Bathing, and Not Applicable was marked indicating no showers were provided. There was no documentation in the ADL Record or the resident's clinical record reflecting the resident was provided with a shower or had refused to be showered.Record review of the facility's shower binder which contained Skin monitoring: Comprehensive CNA Shower Review sheets reflected Resident #1 was missing 07/03/26, 7/06/26, 7/08/26, 07/10/26, 7/15/26 and 07/31/26 shower sheets. Unknown if shower was provided or refused. Shower binder indicated Resident #1 shower days were Monday, Wednesday, Fridays from 2PM-10PM. Interview on 08/12/26 at 12:18 p.m. CNA A stated she was the CNA assigned to Resident #1 during the morning shift. She stated Resident #1 shower days were Monday, Wednesday, and Fridays during the 2PM-10PM shift. She stated she had not provided any showers to Resident #1 during 6AM to 2PM shift. Interview on 08/12/26 at 2:00 p.m. CNA B stated Resident #1 showers were provided during her 2PM-10 PM shift, Monday, Wednesday and Friday. She stated she had provided showers to Resident #1 prior to her discharge. She stated when she would provide her with a shower she would document in PCC and complete a shower sheet. CNA B stated Resident #1 never refused a shower with her. CNA B reviewed Resident #1 ADL record for bathing and stated she was not sure why it was documented Not Applicable. She stated she was not sure what Not Applicable meant. CNA B stated she was not sure why the system was not showing when showers were provided. Interview on 08/12/26 at 2:22 p.m. CNA C stated Resident #1 showers were provided during her 2PM-10 PM shift, Monday, Wednesday and Friday. She stated she provide Resident #1 with her showers on shower days. She stated she would document in PCC (Electronic Health Record) and would complete a shower sheet. She stated all completed shower sheets were placed in the shower binder. CNA C reviewed Resident #1 PCC records and stated she was not sure why the documentation was not correct in PCC. She stated she was not sure what Not Applicable meant, she stated based on documentation it did not appear Resident #1 received any showers; however, the resident did. Interview on 08/12/26 at 2:50 p.m., RN D stated she was the nurse assigned to Resident #1 during the 2PM-10PM shift. She stated Resident #1 received her shower during her shift Monday, Wednesday and Fridays. She stated Resident #1 hardly ever refused any showers, only when she was not feeling well. She stated the CNAs would document showers in PCC and complete shower sheets. She stated she was not aware that in PCC Resident #1's shower days were incorrect. She stated based on documentation it appeared Resident #1 did not receive her showers; however, she would review shower sheets and Resident #1 always received a shower. She stated the potential risk of inaccurate documentation could result in miscommunication on the resident care. 2. Record review of Resident #1's care plan, revised 07/30/26, reflected [Resident #1] is at risk for pressure ulcers andimpaired skin integrity. Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN.Record review of Resident #1's Wound Evaluation & Management Summary, dated 08/04/26 reflected the following Treatment Plan/Orders: (Site 5) Unstageable DTI of the right heel - Initial evaluation undetermined thickness: Skin prep apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of Resident #1's August 2026 physician orders indicated treatment order for skin prep apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days, was not put in the system. Record review of Resident #1's WAR for August 2026 indicated no evidence of wound care was provided to Resident #1 on 08/05/26 for her right heel. Interview on 08/12/26 at 12:02 p.m., Treatment Nurse stated she provided Resident #1's wound care Monday through Friday. She stated during the weekend the weekend supervisor would complete wound care. She stated Resident #1 had surgical wounds that she was treating. Treatment Nurse stated prior to Resident #1 discharged on 08/06/26 a wound was observed on the heel; however, the skin was intact. She stated Resident #1 was seen by the wound care doctor on 08/04/26 and staged the wound as a DTI. She stated she did not complete rounds with the wound care doctor on 08/04/26 because he had arrived later in the day, after her shift had ended. She stated on 08/05/26 she had reviewed the orders and provided wound care to Resident #1 right heel. Treatment Nurse stated she was aware the wound care doctor ordered skin prep once daily. She stated the reviewed Resident #1's physician orders and realized she forgot to put in the order and did not document that she provided wound care on 08/05/26. She stated by the time she was going to put in the orders in the system Resident #1 had already been discharged . Treatment Nurse stated accurate documentation was important to maintain a clear trail of the care provided to the resident. She stated there was no potential risk to Resident #1 because the skin was intact; however, if the wound care was provided but not documented, then the wound care was not completed. Interview on 08/12/26 at 3:39 p.m., the Wound Care Doctor stated that he had completed an assessment on Resident #1 on 08/04/26. He stated he provided an order for daily skin prep. He stated his expectation was that all orders were to be entered into the system, followed as prescribed and document any treatment provided to the resident.Interview on 08/12/26 at 3:52 p.m., the DON stated she was not aware Resident #1's showers were incorrect in the system. She stated in the system it indicated her shower days were Tuesday, Thursday and Saturday during the 6AM to 2PM; however, her showers days were Monday, Wednesday and Fridays during the 2PM -10PM shift. She stated CNAs would complete shower sheets and placed them in the shower binder; however, she was unable to locate the shower sheets for the following days 07/03/26, 7/06/26, 7/08/26, 07/10/26, 7/15/26 and 07/31/26. She stated Resident #1 would receive her showers and never complained about not getting them. She stated by reviewing PCC it appeared showers were not provided to Resident #1. She stated it was a documentation issue, and they relied on PCC documentation. She stated it was her previous ADON responsibility to ensure documentation was accurate and showers were completed. The DON stated when obtaining wound care orders, the expectation was for the treatment nurse to enter the orders and complete the treatment daily. She stated once treatment was completed, she expects the treatment nurse to document. She stated potential risk of not documenting correctly would be further skin breakdowns and infection and no one would know if treatment was provided. Record review of facility Documentation policy, undated, reflected the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC).

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #39) reviewed for medication errors.The facility failed to hold Resident #39's Carvedilol and Hydralazine per the recommended and prescribed heart rate parameters on 06/01/26, 06/04/26, 06/08/26, 06/12/26, 06/13/26, 06/14/26, 06/15/26, 06/16/26, 06/17/26, 06/20/26, 06/21/26, 06/22/26, and 06/24/26.This failure could place residents who receive blood pressure and pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, and potential hospitalization.Findings included: Record review of Resident #39's Annual MDS, dated [DATE], reflected he was a [AGE] year-old male, who admitted on [DATE] with diagnoses that included: hypertension (high blood pressure). The MDS reflected Resident #39's cognition was intact with a BIMS score of 15. Record review of Resident #39's care plan, dated 05/04/26, revealed the resident had hypertension and was receiving medications to manage it with interventions to give anti-hypertensive medications as ordered and monitor for side effects. Record review of Resident #39's June 2026 active physician orders, revealed as follows:*Coreg (Carvedilol) 25 mg (medication used to treat high blood pressure), give 1 tablet by mouth 2 times a day for hypertension, hold for SBP [the pressure in the arteries when the heart beats] < 100 and DBP [the pressure of blood pushing against the artery walls while the heart rests] <60 or HR [the speed at which the heart beats] <60, with a start date of 03/11/25. *Hyralazine 100 mg (medication used to treat high blood pressure), give 1 tablet by mouth 3 times a day, hold for SBP < 100 and DBP <60 or HR <60, with a start state of 01/31/25. Record review of Resident #39's June 2026 MAR revealed 7:00 AM HR vitals: *06/01/26 his HR was 59, *06/04/25 his HR was 59, *06/08/26 his HR was 57, *06/12/26 his HR was 55, *06/13/26 his HR was 59, *06/14/26 his HR was 58, *06/15/26 his HR was 56, *06/16/26 his HR was 59, *06/17/26 his HR was 59, *06/20/26 his HR was 59, *06/21/26 his HR was 58, and *06/22/26 his HR was 55. The MAR revealed that both the Carvedilol and Hydralazine were administered on each of these dates by MA B. During an observation on 06/24/26 at 7:06 AM, MA B obtained Resident #39's vital signs. Resident #39's blood pressure was 139/81 and his HR was 59 beats per minute. MA B was observed administering Resident #39's Carvedilol and Hydralazine, in addition to his other scheduled medications. Resident #39's HR was less than 60. During an interview on 06/24/26 at 7:42 AM with MA B, he stated he did administer the Carvedilol and Hydralazine to Resident #39. He stated the orders stated to hold if the HR was less than 60. He stated Resident #39's HR was 59, so he should not have administered the medications without checking with the nurse first. He stated the check marks on the MAR meant the medications were administered. MA B stated he normally communicated with the nurse and would recheck the vitals for a second or third time, but that he had not notified the nurse. MA B stated he knew not to administer if the BP was lower but had missed the HR. MA B stated the risk of administering blood pressure medications without following the parameters were the blood pressure or HR could become lower. During an interview on 06/24/26 at 9:55 AM with LVN C, she stated most blood pressure medications had parameters and that she expected her medication aides to notify her if the BP or HR were below parameters so she could double check it. LVN C stated she would notify the physician if the vital signs were below the parameters. LVN C stated she had not been notified of Resident #39's vital signs. She stated the risk of not following the parameters was the resident's HR or BP could drop. LVN C stated it was her and the other nurse's responsibility to ensure the medication aides were following the orders. During an interview on 10:11 AM with the DON, she stated she expected her staff to not give medications if it was not within the ordered parameters. She stated the MA was supposed to notify the nurse and the nurse could contact the physician. The DON stated the parameters were in place to protect the resident. She stated the risk of giving medications without following the parameters was the resident could have a reaction to that and it could lower the BP or HR. The DON stated she was ultimately responsible for ensuring the orders were following, but all the nurses as well. The DON stated the MA was responsible for notifying the nurse if the medication was outside of the ordered parameters. During an interview on 06/25/26 at 10:14 AM with the facility's Medical Director, she stated that she expected staff to follow the parameters set on the medications. She stated the nurses were good about notifying her if something was wrong, but that she had not been notified previously regarding Resident #39's HR. The Medical Director stated the risk of not following her order parameters was the HR and BP could decrease more and potentially cause an adverse reaction. During an interview on 06/25/26 at 10:46 AM with the ADON, she stated she expected staff to follow the parameters on any blood pressure medications. She stated there was usually a BP and a pulse parameter on each medication and that staff were supposed to hold it if it was below the parameters. The ADON stated the MA should notify the nurse and the nurse could notify the physician. She stated the nurses were responsible for ensuring the parameters were followed by the MA. The ADON stated the risk of the parameters not being followed was the pulse or blood pressure could drop even lower. Record review of the facility's, Medication Administration Procedures, revise 10/25/17, revealed the following: .20. The 10 rights of medication should always be adhered to 1.Right patient 2.Right medication 3.Right dose 4.Right route 5.Right time6.Right patient education 7.Right Documentation 8.Right to refuse9.Right assessment10.Right Evaluation

Based on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #9) reviewed for oxygen orders. The facility failed to ensure Resident #9 was receiving oxygen at 2-4 liters per minute as ordered by the physician.This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health.Findings included: Record review of Resident #9's Quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, unspecified whether with hypoxia (low levels of oxygen in the body tissues) or hypercapnia (elevated carbon dioxide in the blood), tracheostomy status (an incision in the windpipe made to relieve an obstruction to breathing), respiratory failure, and hypertension (high blood pressure). The MDS reflected that the resident's cognition was intact with a BIMS score of 14, and he received oxygen therapy and tracheostomy care.Record review of Resident #9's care plan, dated 05/27/26, revealed Focus: [Resident #9] has Oxygen Therapy. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for s/sx of respiratory distress and report to MD. Focus: The resident has Pneumonia. Goal: The resident's pneumonia will be resolved without complications by review date. Interventions: Oxygen therapy as ordered. Record review of Resident #9's physician order dated 05/08/26 revealed May use oxygen @_2-4 l/m via trach every shift related to Acute and Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.Observation on 06/23/26 at 11:10 a.m. revealed Resident #9 was in his room, lying in bed sleeping. Resident #9 was receiving 4.5 liters of oxygen via nasal cannula (device that provides oxygen therapy through the nose). Observation and interview on 06/24/26 at 9:35 a.m. with Resident #9 revealed he had his oxygen nasal cannula in place, and the oxygen concentrator (a medical device that provides supplemental oxygen) was set at 5 liters per minute. Resident #9 stated he should be on 3 liters. He stated it felt like he was on 3 liters and not 5 liters. Resident #9 stated he did not have shortness of breath or difficulty breathing. Observation on 06/24/26 at 4:05 p.m. revealed Resident #9 was sleeping with his nasal cannula in place. Resident #9's oxygen concentrator was set at 5 liters per minutes. Observation and interview on 06/25/26 at 10:08 a.m. with Resident #9 revealed he had his oxygen nasal cannula on at 5 liters. Resident #9 denied having any shortness of breath. Resident #9 stated he had not seen anyone adjust his oxygen concentrator. During an observation and interview on 06/25/26 at 10:12 a.m., LVN C stated she was the nurse assigned to Resident #9. She stated Resident #9 was supposed to be on 3 liters of oxygen continuously. LVN C entered Resident #9's room and checked on Resident #9's oxygen flow rate. LVN C stated the resident was not supposed to be on 5 liters. She stated she was not aware Resident #9's oxygen flow rate was at 5 liters. LVN C stated she did not check Resident #9's oxygen flow rate when completing her rounds. She stated that she only checked the humidifier bottle to ensure there was water. She stated she could not recall when the last time she checked on Resident #9's oxygen flow rate. LVN C stated she was also the nurse assigned yesterday (06/24/26), and she did not check the oxygen flow rate. She stated the potential risk of not following physician orders would be harmful to the resident, could cause hypoxia. Interview on 06/25/26 at 10:55 a.m., the ADON stated for residents receiving oxygen all the nurses were expected to check the residents' oxygen levels every shift to ensure they were at the correct oxygen setting, and following physician orders. She stated it was the responsibility of the nurses to ensure oxygen settings were correct. The ADON stated she and the DON were responsible for completing spot checks to ensure the nurses were following physician orders. She stated the potential risk of not following physician orders was that it could exacerbate the residents' symptoms if they were administered too much oxygen. Interview on 06/25/26 at 11:21 a.m., the DON stated for residents receiving oxygen the nurses were expected to check residents' oxygen levels and deliver oxygen per physician orders. She stated the nurses were responsible for ensuring they were following physician orders and ensuring oxygen settings were correct. The DON stated she and the ADONs were responsible for following up and ensuring nurses were following physician orders. She stated if oxygen was not administered correctly, the potential risk for residents would be shortness of breath and anxiety. She stated if residents were administered more than what the orders indicated, it could lead to hyperoxygenation (excessive oxygen in the lungs or other body tissues) and could affect oxygen levels. Record review of the facility's, Oxygen Administration revised 03/21/23, revealed the following: The amount of oxygen by percent of concentration or L/min , and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. 1.The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two of five residents (Resident #1 and Resident #2) reviewed for supervision. 1.) The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1, who was known to have confusion and wandering behaviors, first exited from an exterior door of the facility on 04/01/25. The facility failed to provide adequate supervision, and Resident #1 eloped from the facility on 09/06/25. 2.) The facility failed to ensure the Wander Guard system (an electronic system that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) utilized for Resident #2 was in proper working order. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM. While the IJ was removed on 09/11/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for not being adequately supervised and the potential for serious injury and/or death.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 09/10/25, reflected she was an [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and repeated falls (a personal history of falls). Resident #1 was discharged from the facility on 09/07/25. Record review of Resident #1's MDS Assessment, dated 07/09/25, reflected she had a BIMS score of 04, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #1 was identified as being able to walk 150 feet independently. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #1's Care Plan, dated 07/09/25, reflected an identified focus area of being at-risk for wandering (initiation date 12/31/24, revision date 01/14/25). Goals included for Resident #1's safety to be maintained and for Resident #1 not to leave the facility unattended. Identified interventions included assessing Resident #1 for her risk of falls, distracting Resident #1 from wandering by offering pleasant diversions (structured activities, food, conversation, television, books), identifying a pattern for wandering, staying with Resident #1 and notifying the Charge Nurse if she was exit seeking, monitoring Resident #1 for fatigue and weight loss, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #1's Progress Notes, dated 04/01/25, reflected, .Resident disoriented but easily redirected opened door which activated the alarm. Staff immediately followed resident and walked with resident and assisted her back inside the facility. Resident stated she was searching for her car. Resident assisted back to her room. Record review of Resident #1's Elopement Risk Assessment, dated 04/01/25 (following the wandering/elopement incident), reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #1's Elopement Risk Assessment, dated 07/02/25, reflected she scored a 20.0, indicating she was at an increased risk for elopement. Record review of an Event Report for Resident #1, dated 09/06/25, reflected, .Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Record review of Resident #1's Progress Notes, dated 09/06/25 at 7:44PM, reflected, .The front and back door alarms were sounding, and staff initiated a search for residents. Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Resident was redirected, and safety precautions were reinforced. Will continue to assess the resident closely for changes in condition, ensure door alarms remain functional, and notify the physician and family of the incident. Record review of Resident #1's Elopement Risk Assessment, dated 09/06/25 (following the wandering/elopement incident), reflected she scored a 26.0, indicating she was at an increased risk for elopement. Observation of the path from the exterior door on the 200 Hall to the front of the building in which Resident #1 was located (the path in which it was determined by the facility that Resident #1 walked, after she eloped from the building on 09/06/25) on 09/11/25 at 8:40AM revealed the path was approximately 150 feet in length. During an interview with the ADON on 09/10/25 at 11:22AM, she stated Resident #1 had a history of confusion, and it was not uncommon for her to sundown (a phenomenon where people with dementia or other cognitive impairments experience increased confusion, agitation, and other behavioral changes in the late afternoon and evening hours). The ADON stated Resident #1 had previously gone toward exterior doors before and had even opened an exterior door in the past, but she was always easily redirected. The ADON stated when Resident #1 previously opened an exterior door (04/01/25), a staff member had line-of-sight supervision of her and was able to redirect her back inside. The ADON stated on 09/06/25 at approximately 7:00PM, the front door alarm and the alarm from the exterior door on the 200 Hall were both sounding at the same time. She stated facility staff immediately responded to the alarms. The ADON stated she went outside via the exterior door on the 200 Hall and LVN A went outside via the front door; staff remaining inside were conducting a head count of residents. The ADON stated she did not immediately see anyone when she went outside, so she started to walk around the exterior of the building. When she arrived at the front of the building, she noted LVN A waving her hands and calling her (the ADON) over toward her. The ADON stated when she arrived to where LVN A was standing, she saw Resident #1 sitting between two cars, on the concrete ground. Resident #1 denied being injured and stated she was looking for her car. She was easily redirected and taken back inside of the facility. A head-to-toe assessment revealed no noted injuries. The Administrator was notified of the incident, and Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located at a secured facility the following day. The ADON stated in total, it was about 2-3 minutes from the time the alarms went off until the time Resident #1 was located outside. Through the facility's investigation, it was determined that the front door alarm was sounding because the door had not adequately latched when a visitor had exited the building (a company came out and repaired the latch following the incident). Resident #1 exited through the exterior door of the 200 Hall, which was the reason for that alarm sounding. Following the incident, facility staff were in-serviced on abuse/neglect and elopement prevention/response. The ADON stated the risk of a resident eloping from the facility included the potential for injury. During an interview with LVN A on 09/10/25 at 11:36AM, she stated on 09/06/25 at approximately 7:00PM, the front door alarm started sounding. When staff attempted to immediately disarm the alarm, it was noted that the alarm from the exterior door on the 200 Hall was also sounding. LVN A stated the sound from the front door alarm was overpowering the sound of the alarm from the exterior door on the 200 Hall. Upon realizing that the exterior door on the 200 Hall was also sounding, LVN A said she immediately questioned to available staff, Where is [Resident #1]? LVN A stated this was her first thought because she knew Resident #1 had a history of sundowning, packing up her belongings, and attempting to exit from the exterior door on the 200 Hall. LVN A stated she went to Resident #1's room and noticed the top drawer of her dresser was out (as though she was potentially packing up her belongings), and she was not in the restroom. LVN A stated she immediately went outside and started searching for Resident #1. She found Resident #1 in the front of the building, sitting between two parked cars. Resident #1 was confused; she stated she had found her car and was trying to get in it. LVN A stated she waved facility staff over toward her and Resident #1 was assisted back inside the building. She was clearly confused but had no signs of injury. She was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. LVN A stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. LVN A stated the risk of a resident eloping from the facility included the potential for injury. During an interview with the Administrator in Training on 09/10/25 at 11:44AM, she stated Resident #1 had a history of wandering and sundowning; she had also previously exited from an exterior door (04/01/25). The Administrator in Training stated the facility's policy was to find alternate, secured placement for residents who began showing signs of exit-seeking behavior. She stated she was not sure why Resident #1 was allowed to stay at the facility following the incident in April of 2025; she believed it must have been because she was always easily redirected. The Administrator in Training stated she responded to the most recent incident involving Resident #1's elopement (09/06/25), as the Administrator was on leave at that time. The Administrator in Training stated she came to the facility following the incident, after she had been notified by the ADON that Resident #1 eloped. The Administrator in Training stated it was her understanding that Resident #1 eloped from the exterior door on the 200 Hall. She was found within just a few minutes by facility staff and was easily redirected and brought back inside the building. She denied the presence of pain and did not sustain any injuries. Her family and physician were notified of the incident. Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. The Administrator in Training stated Resident #1 did not have a Wander Guard bracelet (an electronic device that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) at the time of the incident. The Administrator in Training stated there was one resident at the facility (Resident #2) who utilized a Wander Guard bracelet, but aside from that, the facility stopped ordering them. Following the incident, the Administrator in Training stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. During an interview with the Administrator on 09/10/25 at 12:05PM, she stated she was on leave when the incident involving Resident #1's elopement occurred (09/06/25). She stated the Administrator in Training responded to the incident. The Administrator stated Resident #1 initially admitted to the facility in December of 2024; she was very ambulatory, so she was placed on 1:1 supervision/monitoring to ensure she would adjust appropriately to the facility. She did not display any exit-seeking behaviors, so 1:1 supervision/monitoring was discontinued. She continued to reside at the facility without incident until 04/01/25, when she opened the exterior door on the 200 Hall. A staff member saw her open the door, walked with her and redirected her back inside. A staff member was with her at all times during that incident. The Administrator stated the incident was discussed amongst facility staff and they did not think Resident #1 was actually trying to elope from the building, so she was allowed to stay at the facility. She stated if a resident was truly trying to elope from the building, then that resident would be moved to a sister facility with a secured unit. The Administrator stated the facility was trying to get away from the use of Wander Guard bracelets, which was why Resident #1 did not have one at the time of the incident on 09/06/25. The Administrator stated the risk of a resident eloping from the facility included the potential for harm and/or death. 2.) Record review of Resident #2's Face Sheet, dated 09/10/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's MDS Assessment, dated 06/13/25, reflected she had a BIMS score of 03, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #2 was identified as being able to walk 10 feet with partial/moderate assistance from staff. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #2's Care Plan, dated 07/01/25, reflected an identified focus area of being at-risk for injuries/elopement due to wandering behaviors and wandering with poor safety awareness. This focus area also identified Resident #2 as wearing a Wander Guard bracelet (initiation date 11/21/22, revision date 01/21/25). Goals included for Resident #2 to have no elopements/injuries due to wandering behaviors. Identified interventions included assessing Resident #2 for her risk of falls, distracting Resident #2 from wandering by offering pleasant diversions (structured activities, food, conversation, television), identifying a pattern for wandering, staying with Resident #2 and notifying the Charge Nurse if she was exit seeking, monitoring the placement of the Wander Guard bracelet each shift, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #2's Physician's Orders, dated 09/10/25, reflected, .Monitor Wander Guard to right lower leg for placement, function, and skin integrity every shift. The start date for this order was 10/18/24 and there was no set end date. Record review of Resident #2's September 2025 Medication Administration Record/Treatment Administration Record, dated 09/10/25, reflected facility staff documented confirming the placement, function, and skin integrity for Resident #2's Wander Guard bracelet every shift. Record review of Resident #2's Elopement Risk Assessment, dated 07/21/25, reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #2's Elopement Risk Assessment, dated 09/06/25, reflected she scored an 11.0, indicating she was at an increased risk for elopement. Observation of Resident #2 on 09/10/25 at 11:55AM revealed she was wearing a Wander Guard bracelet on her ankle. Observation revealed the front door of the facility (the door which was equipped with a Wander Guard alarm system; all other exterior doors were fire alarm doors with controlled egress locks) did not automatically lock, as it should have, when Resident #2 was within one foot of the door. This occurred on two out of three attempts of verification of the functionality of the Wander Guard alarm system. The Administrator and the Administrator in Training both verified this observation. During an interview with the Administrator of 09/10/25 at 12:05PM, she stated she would ensure the Wander Guard alarm system was fixed today. She stated Resident #2 had been placed on 1:1 supervision/monitoring until it could be fixed. The Administrator stated she herself had verified the Wander Guard alarm system was working multiple times within the past few days, as a result of the investigation following Resident #1's elopement. Record review of the facility's Elopement Prevention Policy, dated 01/2023, reflected, .Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. and .All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices included Wander Guard systems (locking or alarming), keypad exit magnetic locks, keyed alarms, secured units, and/or a combination of these interventions. Record review of the facility's Elopement Response Policy, dated 01/2023, reflected, .Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be implemented immediately. and .A resident is determined to be missing when he/she leaves the facility without the staff's knowledge. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM and signed by the Administrator. A Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 09/11/25 at 5:51AM and reflected the following: .Interventions: Resident #1 no longer resides in the facility as of 9-10-25. Resident #2 was placed on 1:1 supervision by DON/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. Line of sight monitoring for the front door initiated by Admin/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. An audit was completed on all residents in the facility to determine if they are at risk for elopement by Regional Compliance Nurse on 9.10.25. Resident #2 was the only resident identified as an elopement risk as of 9-10-25. IDT will review elopement risk scores on admission and quarterly. A Secure Care Consult while [sic] be requested by the DON/Designee to assist with ensuring appropriate placement and interventions if a resident is at risk. Administrator contacted Fire Protection vendor to inspect the doors and alarms on 9-8-25. Fire Protection vendor ensured the annunciator panel at the nurse's station was functioning and alarming properly. This was completed on 9-9-25. Administrator contacted Fire Protection vendor to inspect the front door to ensure proper functioning of the Wander Guard system. The front door will now be locked 24 hrs per day and 7 days per week and the latch was fixed. Completed on 9-10-25. The medical director was notified by the Administrator of the immediate jeopardy on 9-10-25. An Ad Hoc QAPI meeting to include the medical director was conducted on 9-10-25 to review the immediate jeopardy citation and subsequent plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 9-10-25 on the following: Abuse/Neglect Policy Proper functioning of the Wander Guard systemElopement Prevention and Response In-services: All staff will be in-serviced on 9.10.25 by the Admin/designee regarding the following and all staff not in-serviced by 9.10.25 will not be allowed to work their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Admin and ADON were in-serviced by Compliance Nurse. Abuse and NeglectProper functioning of the Wander Guard system Elopement Prevention and Response. The facility's implementation of the Plan of Removal was verified through the following: Record review of the facility's Resident Roster, dated 09/11/25, reflected Resident #1 was not listed as a current resident. Observations of Resident #2 on 09/10/25 at 2:17PM and on 09/11/25 at 8:27AM revealed she was being provided with 1:1 supervision/monitoring by facility staff. Observation of the facility's front door on 09/11/25 at 9:23AM revealed the door was securely locked. Upon opening the door and allowing it to close, the latch secured properly and the door automatically locked. Resident #2, who was wearing her ordered Wander Guard bracelet on her ankle, was brought within one foot of the door, and the door remained locked. Observation of the annunciation panel (a panel that provides both visible and audible indications to alert caregivers about the status of alarmed doors) for the door alarm system on 09/11/25 at 9:28AM revealed when multiple alarms were sounding, the front door alarm did not overpower other alarms. All alarms sounding were able to be heard. Record review of Resident #1's Face Sheet, dated 09/10/25, reflected Resident #1 was discharged from the facility on 09/07/25. Record review of a 1:1 Supervision/Monitoring Log for Resident #2, dated 09/10/25, reflected Resident #2 had been provided with 1:1 supervision/monitoring by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of a Line of Sight Door Monitoring Log, dated 09/10/25, reflected there was line of sight monitoring of the front door at the facility by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of an Elopement Risk Assessment History audit, dated 09/10/25, reflected Resident #2 was the only resident present at the facility who was identified as being at-risk for elopement. Record review of in-service logs, dated 09/10/25, reflected facility staff members had been in-serviced on areas including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. During interviews with multiple staff members who represented all departments and all assigned shifts (MDS Coordinator, Social Worker, Business Office Manager, Dietary Manager, Maintenance Director, Housekeeping Supervisor, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, RN G, CNA H, CNA I, CNA J, CNA K, CNA L, and MA M) on 09/11/25 between 5:38AM 9:15AM, they each reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas, as well as how they would respond to resident changes of condition, residents who were wandering, missing residents, etc. These staff members appeared knowledgeable on the facility's policies and procedures. They each verbalized being aware that the facility had one resident with a Wander Guard system in place (Resident #2). These staff members reported that there had been no previous attempts of elopement by Resident #2, but the Wander Guard was in place as a prevention method due to her increased risk of elopement. These interviews were conducted without incident or concern regarding the trainings provided. During interviews with the Administrator, the Administrator in Training, and the ADON on 09/11/25 between 7:45AM and 9:05AM, they reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members appeared knowledgeable on the facility's policies and procedures. It was reported that the facility's Interdisciplinary Team (IDT) would review elopement risk scores on admission and quarterly; if a resident was identified as being at-risk for elopement, a Secure Care Consult would be requested to assist in ensuring appropriate placement and interventions. It was also reported that a QAA/QAPI meeting was held on 09/10/25 to review the Immediate Jeopardy citation and discuss the plan of removal. The Administrator stated she would be responsible for overseeing the plan and would notify the Regional Compliance Nurse of any negative findings. The Administrator was notified the IJ was removed on 09/11/25 at 9:35AM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted her on 04/29/25 in Resident #3's room. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's admission record, dated 06/26/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #1's Annual MDS Assessment, dated 03/17/25, reflected she had a BIMS of 03, indicating severe cognitive impairment. Her active diagnoses included non-traumatic brain dysfunction (refers to brain damage caused by factors other than external trauma), non-alzheimer's dementia (loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities), anxiety disorder (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #1's care plan reflected the following: Focus: [Resident #1] has a potential psychosocial well-being problem r/t potential altercation with another resident .Interventions: Monitor/document residents feelings relative to (i.e [sic] isolation, unhappiness, anger). Date Initiated: 04/29/25 .Skin assessment, Pain assessment, Trauma Informed Care, MD and RP notified .The resident needs assistance/encouragement/support to identify precipitating factors, and stressors . Record review of Resident #1's Trauma Informed PRN Assessment, dated 04/29/25, reflected there was no indication the resident had recalled the situation. Record review of Resident #1's Weekly Skin Assessment, dated 04/29/25, reflected she had a bruise and laceration, but it did not specify any additional details. Record review of Resident #1's Weekly Skin Assessment, dated 05/06/25, reflected she had a bruise described as: Right forearm: bruising to the dorsal aspect measuring 5.5 cm x 4.5 cm; Adjacent Bruising lateral to the first, measuring 2.5 cm x 3.5 cm; Bruising to right lateral forearm, measuring 3 cm x 2.5 cm; Right hand: Bruising near the base of the thumb, lateral aspect,.08 cm [sic] x .2 cm; Bruising to dorsum of hand 3.5 cm x 2.5 cm; Left arm: Bruising near the elbow, 3.5 cm x 2.5 cm; Left hand: Bruise measuring 0.7 cm x 0.1 cm; Right lower extremity: Bruising to the right shin, 3.5 cm x 2.5 cm, Bruising to right knee, measuring 6 cm x 3 cm and a laceration described as: Laceration to the right shin, measuring 1 cm x 0.8 cm x .1 cm. Record review of Resident #1's x-ray report, dated 04/29/25, reflected there was no evidence of a fracture or dislocation. Record review of Resident #1's Progress Notes reflected the following: - On 04/29/25 at 4:00 PM, the WCN wrote: Weekly Skin Assessment .Bruise present: Yes. Location, measurements of bruising: Right forearm: bruising to the dorsal aspect measuring 5.5 cm x 4.5 cm; Adjacent Bruising lateral to the first, measuring 2.5 cm x 3.5 cm; Bruising to right lateral forearm, measuring 3 cm x 2.5 cm; Right hand: Bruising near the base of the thumb, lateral aspect,.08 cm [sic] x .2 cm; Bruising to dorsum of hand 3.5 cm x 2.5 cm; Left arm: Bruising near the elbow, 3.5 cm x 2.5 cm; Left hand: Bruise measuring 0.7 cm x 0.1 cm; Right lower extremity: Bruising to the right shin, 3.5 cm x 2.5 cm, Bruising to right knee, measuring 6 cm x 3 cm and Laceration is 0.6 cm x 0.6 cm .Laceration present: Yes. Location, measurements of laceration: Right hand: dorsum of hand, a pinpoint opening noted within the contusion. Left arm, Left temple: Laceration present, measuring 3 cm x 2 cm. Left hand, Right lower extremity: Laceration to the right shin, measuring 1 cm x 0.6 cm. Laceration to right knee, measuring 0.6 cm x 0.6 cm . - On 04/29/25 at 7:58 PM, the WCN wrote: Skin assessment completed. Multiple contusions and lacerations noted: .Contusion and laceration to the right shin, measuring 3.5 cm x 2.5 cm, with an open area within the contusion measuring 1 cm x 0.6 cm. Contusion and Laceration [sic] to right knee, measuring 6 cm x 3 cm and Laceration [sic] is 0.6 cm x 0.6 cm .Patient tolerated assessment without complaints. Wounds to be monitored per protocol. - On 04/29/25 at 7:59 PM, the WCN wrote: Injury Follow-Up .Swelling Present, Painful, Pain appear to be present: Yes Location [sic] of resident pain: right knee and shin Pain [sic] is described as: unable to specify due to dementia Pain [sic] relieving interventions: Tylenol as ordered .Interventions: .The assailant was removed from the building immediately . - On 04/29/25 at 9:31 PM, RN A wrote: Resident was in another resident's room when staff entered the room and observed other resident holding a footrest to a wheelchair in his hand. Upon seeing staff, he immediately dropped the footrest to the floor. [Resident #1] was noted to have a small amount of blood to her left forehead, lacerations to right knee and shin, three raised red areas to right forearm and two raised red areas to left forearm. Resident was immediately removed from room and assessed by nurse. The other resident was removed from room and placed on 1 on 1 monitoring until transported to local hospital. MD and family notified. - On 04/29/25 at 9:44 AM, RN A wrote: .Resident has multiple lacerations with small amount of blood coming out on her legs , [sic] knees, left side of the head, some bumps in her hands . - On 04/30/25 at 12:54 AM, LVN B wrote: xray [sic] results received sent to [Physician C ] and poa notified no fracture [sic] or dislocation noted. -On 05/02/25 at 6:10 PM, the SW wrote: Resident is doing well. No distress over incident with another resident earlier this week. No recollection of incident at all. Observation and attempted interview on 06/26/25 at 9:21 AM with Resident #1 revealed she was in her room eating breakfast. Resident #1 did not have any signs of injuries to her that could be seen. Resident #1 said no one had ever tried to hurt or hit her. Resident #1 said she felt safe in the facility. Record review of Resident #2's face sheet, dated 06/26/25, reflected an [AGE] year-old male who originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on 05/05/25. Record review of Resident #2's MDS Assessment, dated 05/05/25, reflected a BIMS score was not calculated. His MDS indicated he had physical behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. His active diagnoses included unspecified dementia (loss of cognitive functioning, including memory, language, and problem-solving abilities, that is severe enough to interfere with daily life) and recurrent depressive disorder (a mental health condition characterized by repeated episodes of deep sadness, hopelessness, and loss of interest in daily activities). Record review of Resident #2's care plan reflected the following: Focus: [Resident #2] has potential to demonstrate physical behaviors due to Dementia, Date Initiated: 04/29/25 .Interventions: 1:1 monitoring, Skin assessment, Psych follow up, Med review w/ med [sic] adjustment, MD and NP notified .If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Notify the charge nurse of any physically abusive behaviors .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #2's Progress Notes reflected the following: - On 04/09/25 at 5:43 AM, LVN D wrote: Resident is very combative; he refuses to go to bed and wanders in other residents 'rooms. [sic] this nurse has redirected him multiple times but resident refuses to listen and try to fight. - On 04/10/25 at 11:44 AM, LVN E wrote: res [sic] in dining room stealing residents belongings. staff [sic] tried to get belongings back and res became very agitated with staff and hit one staff member and bit the nurse on the forearm. staff [sic] trying to explain that he cant [sic] be taking stuff from other residents. will [sic] cont to monitor resident. - On 04/19/25 at 3:31 PM, the WCN wrote: Behavioral Incident: At approximately [9:00 AM], [Resident #2] exited his room without wearing pants or undergarments, exposing his genitalia in a public area. When nursing staff approached to redirect him to his room for redressing, he became combative and attempted to fight staff. Staff ensured safety precautions were followed during redirection. At approximately [2:30 PM], [Resident #2] began to remove his pants and exposed his genitals while walking toward the dining room. Staff promptly intervened, redirected him to his room, and assisted with redressing. Currently, [Resident #2] is ambulating in the 300 Hall. He is no longer exhibiting irate behavior but continues towander [sic]. Staff will continue to monitor closely for safety and further behavioral concerns. - On 04/24/25 at 9:32 PM, LVN E wrote: combative [sic] with staff and refused to shower or let aide help him toilet . - On 04/25/25 at 3:36 PM, the SW wrote: Call placed to [Resident #2's RP] to inform him that we needed to seek alternate placement for resident due to combative behaviors with staff and wandering in to other res rooms. [Resident #2's RP] verbalized understanding and agreement . - On 04/29/25 at 5:24 PM, LVN E wrote: [Resident #2] was observed by staff member in another resident's room sitting in his wheelchair holding a foot rest [sic] to a wheelchair in the air. When this writer walked in the room, [Resident #2] dropped the foot rest [sic] on floor [sic]. The other resident was observed with blood noted to left side of forehead and right shin and two raised red areas to right forearm. The other resident was immediately removed from the room and was assessed by nurse. [Resident #2] was placed on 1 on 1 monitoring. Family, police and EMS were called and resident was transported to hospital [sic] via police accompanied by [Resident #2's family]. - On 04/29/25 at 7:07 PM, LVN E wrote: [Resident #2] was transferred to a hospital on [DATE] at 3:00 PM related to police came and escorted resident to [Hospital Name] to evaluation and treatment [sic]. - On 04/30/25 at 12:15 AM, LVN F wrote: res back to facility via EMS Transportation [sic], received new orders from the hospital to start amoxicillin 500mg [sic] tablet, to be given orally twice daily x10 days and azithromycin 250 mg tablet to be taken as directed for pneumonia. res [sic] assessed, he is awake and alert and able to answer questions in a coherent manner. he [sic] doesn't appear in distress, helped put to bed, no skin issues head to toe assessment done. family [sic], administrator and md notified or res return. - On 04/30/25 at 3:00 AM, LVN F wrote: .attempts to calm him down to no effect as he fights and is combative trying to hit staff who are helpinghim [sic] with wheelchair foot pedals . - On 05/05/25 at 2:10 PM, LVN G wrote: Pt left facility at 210pm [sic]. discharged to [NF Name, Address, and Phone Number]. Left with all belongings including medication and clothing. Sent via transport with family by side. Interview on 06/26/25 at 1:19 PM with LVN I who said she recalled Resident #2 having behaviors because he had bit her one time. LVN I said she also saw Resident #2 hit a staff member as well. LVN I said Resident #2 had a behavior or stealing items from other residents and staff tried to prevent him from doing that but he would swing and kick at staff when they tried to redirect him. LVN I said she did not know about the altercation that happened between Residents #1 and #2. LVN I said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:41 PM with CNA J who said she recalled Resident #2 being very aggressive because he would fight the staff. CNA J said Resident #2 would get made at staff when they tried to redirect him. CNA J she knew of the incident that occurred between Residents #1 and #2 but she never saw Resident #1's injuries. CNA J said she only knew that because of Resident #1's injuries the day after it happened, she had to keep her in bed. CNA J said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:55 PM with MA K who said he recalled Resident #2 lived here briefly but had already left. MA K said Resident #2 had behaviors where he displayed anger and got mad and would throw things and was very agitated. MA K said he did not know what happened between Residents #1 and #2. MA K said he had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:57 PM with CNA L who said she could not recall Resident #2 and did not know about what happened between Residents #1 and #2. CNA L said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:09 PM with LVN G who said she had cared for Resident #2 one time, and he hit her once on her hand when she was trying to redirect him. LVN G said Resident #2 had a habit of going to other residents' rooms and taking their items. LVN G said she had to redirect Resident #2 often. LVN G said she did not know about what happened between Residents #1 and #2. LVN G said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:38 PM with CNA M who said she had cared for Resident #2, and he refused all care and would never let anyone touch him. CNA M said Resident #2 would also curse staff out in Spanish and would put furniture in front of his door on the inside so staff could not enter his room. CNA M said she saw Resident #1 after the incident with Resident #2 and said she was beaten with some sort of stick. CNA M said Resident #1 was bleeding badly, her head was swollen, her knee was bleeding, and her arms had bruises on them. CNA M said Resident #1 did not recall what happened to her. CNA M said from what she understood, a different CNA saw the incident happen between Residents #1 and #2 so the nurse on duty was alerted and the administrator was informed. CNA M said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Record review of witness statement completed by CNA H, dated 04/29/25, reflected the following: On April 29th I was walking the hall after arriving for my shift I [sic] noticed that [Resident #3] room [sic] door was closed was shut [sic] that is why I proceeded to open it that is [sic] when I seen [sic] that [Resident #2] was in [Resident #3's] rom and was holding the wheelchair foot rest [sic] in his hand in the air while aggressively talking to [Resident #1] while she was just sitting there that is [sic] when I entered the room and asked [Resident #1] if she was okay and if [Resident #2] hit her she said [sic] that he hit her on her hand, knee, leg and the side of her face head [sic] so I proceeded to remove [Resident #1] from the room on to the front of the door away from [Resident #2] and called the nurse over and explain [sic] what I witness [sic] and showed her that [Resident #1] was bleeding. Interview on 06/26/25 at 2:49 PM on the phone with CNA H revealed she no longer worked at the facility and could not say what actually happened between Residents #1 and #2. CNA H said that she was walking down the hall and noticed Resident #3's door was closed but she was a fall risk, so she went to open the door and noticed Resident #1 in the room with Resident #2. CNA H said she walked into the room and noticed Resident #2 had a footrest from a wheelchair in his hand and he was waving it towards Resident #1. CNA H said she immediately separated the residents and took Resident #1 out of the room, asked her if she was okay, and Resident #1 told her no, he hit me. CNA H said once she got to the hallway with Resident #1, she faced towards the resident and noticed she was bleeding, had contusions to her head, knee, and foot. CNA H said she took Resident #1 to the nurse's station and told the nurse on duty what had happened. CNA H said she then tried to get Resident #2 out of Resident #3's room but he had a behavior of being aggressive towards staff. CNA H said she tried to reorient and redirect Resident #2 and started to remove him from the situation and talk to him afterwards. CNA H said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:53 PM with CNA N who said she did not know about the situation that happened between Residents #1 and #2. CNA N said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Record review of a witness statement completed by LVN E, dated 04/29/25, reflected the following: Writer was called in room [sic] by staff. [Resident #2] was in another resident's room. When writer walked in he was holding a foot rest [sic] in L hand [sic] and dropped it. Another female resident was noted with injuries when asked what occurred 'stated, he hit her' [sic]. He was asked to leave the room and refused, stayed one-on-one with resident until he exited room. Interview on 06/26/25 at 3:03 PM with LVN E who said she was told by the aide who came to get her that Resident #1 was found near Resident #3's bed bleeding. LVN E said the aide told her that Resident #2 was also in the room and had something in his hand and he dropped it. LVN E said when she assessed Resident #1, she was bleeding from her head and leg, so she provided first aide. LVN E said Resident #2 had behaviors of lashing out towards staff verbally, did not want to take his medications, and had a habit of going to other rooms and taking their items. LVN E said staff tried to redirect Resident #2 and keep him as busy as possible, but it was hard to focus on just one resident at all times. LVN E said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 3:14 PM with RN O who said she only heard that Resident #2 hit Resident #1 with a wheelchair footrest. RN O said Resident #2 would show behaviors of being physically aggressive and did not allow staff to care for him. RN O said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 11:01 AM with the SW who said Resident #2 could be short tempered and was easily agitated or aggravated. The SW said Resident #2 had a behavior of assaulting staff before this incident happened with Resident #1 but had not gone after residents that she was aware of. The SW said after the residents were separated immediately following the incident, she was told to start seeking alternate placement for Resident #2. The SW said the facility was already in the process of transferring him to another facility due to his behaviors with staff because it made it hard to care for him. The SW said the facility requested Resident #2's family to also come and sit with him to help manage his behaviors as he was also placed on one-to-one until he discharged to a different facility. The SW said Resident #2 was also moved down the hall where he kept wandering towards because he was convinced that was where his room was. The SW said she talked to Resident #1 who was a poor historian and could not recall what had happened to her. Interview on 06/27/25 at 11:48 AM with the WCN who said she completed a skin assessment on Resident #1 after the incident between her and Resident #2. The WCN said from what she remembered, Resident #1 had a gash to her temple on her right side, another gash to her lower right leg, both of which took time to get those two to stop bleeding. The WCN said Resident #1 also had contusions, 3 on her arm where she assumed the resident was trying to guard herself from the hits by Resident #2. The WCN said Resident #1 also had a few injuries to her hand as well. The WCN said she applied first aid to Resident #1 and the wound care doctor came to round on her two or three times before her injuries were healed. The WCN said Resident #1 could not remember what happened to her since she had severe dementia. The WCN said Resident #3 was in her room where all of this happened between Residents #1 and #2. The WCN said Resident #3 told her that Resident #2 had a footrest from a wheelchair that he used to hit Resident #1 with that caused the gashes to her body. The WCN said when Resident #2 first admitted to the facility he had behaviors, which the facility thought was related to his blood sugar levels being very brittle. The WCN said later on, they learned his behaviors were not related to his blood sugar levels. The WCN said Resident #2 seemed to be targeting women for some reason so he was placed on one-to-one and every 15 minute checks. The WCN said Resident #2 often went down the 500 hallway even though his room was not on that hall, so staff had to redirect him back to his own room. The WCN said Resident #2 was a very strong guy and the facility could not figure out what his triggers were. The WCN said Resident #2 never harmed other residents that she knew of but was physically aggressive with staff. The WCN said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 11:58 AM with the ADON revealed she was told that Resident #2 was in a room on the 500 hallway which was not his hall but he was fixated on that hall for some reason. The ADON said Resident #1 was in Resident #3's room visiting when Resident #2 entered. The ADON said a CNA was walking down the hallway and saw Resident #3's door closed which was unusual so she opened it and saw Resident #2 with a footrest in his hand and Resident #1 did not look like herself. The ADON said she saw the skin tears to Resident #1 and put two and two together. The ADON said the CNA separated the two residents and brought Resident #1 to the nurse's station so she could be assessed. The ADON said the facility also ordered x-rays, notified the doctor, and got psych involved as well. The ADON said the facility began to look for alternate placement for Resident #2, but in the meantime, he was placed on one-on-one and every 15-minute checks until he discharged . The ADON said Resident #1's injuries included skin tears to her knuckles, a laceration to her forehead on the left side by her ear, injuries to her arms with a couple of skin tears, and a laceration to her right shin. The ADON said Resident #1 was not able to say what had happened to her. The ADON said it happened in Resident #3's room but when asked, she only stated she had stayed out of it. The ADON said that Resident #3 seemed to be confused, thinking that what was happening was a domestic dispute between a couple. The ADON said Resident #2 had behaviors that included thinking other resident items were his. The ADON said once he thought an item was his he would begin to go after it, even if it was in another resident's room. The ADON said staff tried to redirect him but it happened often. The ADON said she and other staff had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 12:16 PM with the Administrator revealed the facility did not currently have a DON at the facility. The Administrator said it was reported to her that a CNA walked in and Residents #1 and #2 were in Resident #3's room. The Administrator said Resident #3 was in her bed and Resident #2 was holding a footrest up in the air yelling. The Administrator said Resident #1 was taken out of the room and had scratches or a laceration on the side of her temporal, redness on her arms and scratches, and some injury on her knee. The Administrator said Resident #2 was immediately placed on one-to-one and the facility began searching for somewhere else to send him. The Administrator said Resident #1 was not able to say what had happened to her, and neither could Resident #3. The Administrator said Resident #2 had verbal behaviors because he would curse staff out often, but he never hit another resident that she knew of. The Administrator said staff would see Resident #2 escalating in the dining room so staff would move him away and he would calm down. The Administrator said Resident #2 would also fight staff while receiving care. The Administrator said after the incident occurred, all staff were in-serviced regarding de-escalation techniques, abuse, and resident-to-resident altercations. The Administrator said anytime someone was assaulted, that would be considered abuse. The Administrator said in the situation involving Residents #1 and #2, Resident #2 had physically abused Resident #1. The Administrator said all staff had been trained to identify abuse and intervene beforehand. The Administrator said all residents had the right to be free from abuse and all staff were responsible for providing that right for them. The Administrator said anything could happen if a resident was not free from abuse, including injury or emotional trauma. The Administrator said all staff should be making rounds, assessing residents, and checking for any sign or symptom of abuse. Record review of the facility's Provider Investigation Report reflected the following: Provider Response: [Resident #1] was immediately removed from room and assesses [sic] and treated by nurse. [Resident #2] was placed on 1 on 1 monitoring. Administrator obtained witness statements from staff and residents. MD, family, and EMS/Police notified. Social Worker completed trauma informed assessment on all residents involved with no negative findings. Facility completed x-rays on [Resident #1] with no negative findings. [Resident #2] was sent to hospital for evaluation on 4/29/25. Resident returned to facility on 4/29/25 with new diagnosis of Pneumonia and new orders for antibiotics. Psych MD reviewed medications and added new order for Risperidone. Also, obtained order from Medical Director for Tylenol BID and order to obtain CBC, BMP and UA on [Resident #2]. Social Worker began seeking placement for [Resident #2] at alternate facilities. Staff inserviced [sic] on Abuse & Neglect/Resident to Resident Altercations-Deescalation [sic]. [Resident #1] sustained minor injuries that did not require hospital treatment .Investigation Summary: Both residents involved in incident have diagnosis of dementia. [Resident #2] denied hitting [Resident #1]. [Resident #1] and [Resident #3] stated that [Resident #2] hit [Resident #1]. However, upon reinterview on 4/30/25 with [Resident #1] and [Resident #3], neither resident could recall the incident .Facility Investigation Findings: Confirmed .Provider Action Taken Post-Investigation: .[Resident #2] was discharged to another facility with memory [sic] care unit on 5/5/25. Record review of a witness statement completed by the ADON, dated 04/29/25, reflected the following: This nurse interviewed 3 residents in regard to the resident-to-resident altercation with [Resident #2] and [Resident #1]. Please read below for all statements. [Resident #1]- 'no one has done anything to me'. When asked is she hurt she rubbed her knees and thigh on the right side .[Resident #3]- 'that man had that thing in his hand swinging it hitting that woman. No. he [sic] didn't hit me. I stayed away from him.' [Resident #3]- translator present 'I didn't do anything she was in my room.' I want her out' [sic] Resident remains on 1 on 1 supervision. Record review of five safe surveys completed with residents revealed they felt safe in the facility. Record review of an in-service record, dated 04/29/25, and titled Abuse & Neglect/Res to Res Altercations revealed 60 staff signatures indicating they had been in-serviced. Record review of the facility's Abuse/Negelct policy, revised 09/09/24, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 18 residents (Residents #5, #20, and #34) reviewed for ADLs. 1. The facility failed to ensure Resident #20 and Resident #5's fingernails were cleaned and cut. 2. The facility failed to ensure Resident #34 received regular oral care. This failure had the potential to affect residents by placing them at risk for poor personal hygiene, decreased self-esteem, and a decline in their quality of life. Findings included: 1. Record review of Resident #20's Face sheet, dated 04/17/25, revealed the resident was a [AGE] year-old female with an admitted [DATE] and readmitted on [DATE]. Record review of Resident #20's quarterly MDS assessment dated [DATE] reflected her diagnoses included atherosclerotic heart disease, dysphagia, chronic pain, and essential hypertension (high blood pressure). Resident #20's BIMS score was 08, which indicated moderate cognitive impairment. The MDS further revealed Section G: Activities of Daily Living Assistance revealed Resident #20 required extensive assistance for ADLs. Record review of Resident #20's Care Plan, revised 01/09/25, reflected Focus: [Resident #20] has an ADL Self Care Performance Deficit. Goal: [Resident #20] will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use, and Personal Hygiene; ADL Score) through the review date. Interventions: Assist with personal hygiene as required: hair, shaving, oral care as needed Observation on 04/15/25 at 10:20 AM of Resident #20 in bed sleeping. Observed Resident #20's fingernails to be long, approximately close to an inch long and had yellow build-up underneath her nails. In an interview on 04/17/25 at 10:20 AM, Resident #20 stated she was doing well. Resident #20 was unable to answer further questions regarding her fingernails. In an interview and observation on 04/17/25 at 10:30 AM, CNA J revealed she was the CNA assigned to Resident #20. CNA J looked at Resident #20's fingernails, and she stated the resident's nails were long. She stated the resident's fingernails should be cut by the nurses. She was unaware of how long Resident #20's fingernails were. She stated she did not usually work with Resident #20. In an interview and observation on 04/17/25 at 10:48 AM, RN I stated she was the nurse assigned to Resident #20. She stated residents, who were diabetic, had their fingernails cut by the nurses, and the podiatrist cut their toenails. She stated CNAs and nurses were responsible for cutting the fingernails of non-diabetic residents. RN I looked Resident #20's fingernails. She stated she was unaware of how long Resident #20's fingernails were. She stated fingernails were about 1/2 inch or inch long. She stated she was unsure if the resident refused for her nails to be cut. She stated the potential risk of not cutting or trimming fingernails would be infections or the resident scratching herself. Record review of Resident #5's Face sheet, dated 04/17/25, revealed the resident was a [AGE] year-old female with an admitted [DATE]. Record review of Resident #5's annual MDS assessment dated [DATE] reflected her diagnoses included unspecified dementia, contracture, left hand, and essential hypertension (high blood pressure). Resident #10's BIMS score was 08 which indicated moderate cognition impairment. The MDS further revealed Section G: Activities of Daily Living Assistance revealed Resident #5 required extensive assistance for ADLs. Record review of Resident #5's Care Plan, revised 01/09/25, reflected Focus: [Resident #5] has an ADL Self Care Performance Deficit. Goal: [Resident #5] will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use, and Personal Hygiene; ADL Score) through the review date. Interventions: Assist with personal hygiene as required: hair, shaving, oral care as needed. BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Record review of Resident #5's Kardex, dated 04/17/25, revealed: Resident Care: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. In an interview and observation on 04/17/25 at 10:58 AM, Resident #5 revealed she wanted her fingernails cut. Resident #5's left hand was contracted, and the resident was able to open her hand. The resident's fingernails were long and had build-up underneath. Resident #5 stated she could not recall when the last time was her fingernails on her left hand were cut. Resident #5 stated her middle fingernail was the longest, and it was starting to bother her. In an interview and observation on 04/17/25 at 12:03 PM, CNA J revealed she was the CNA assigned to Resident #5. She observed Resident #5's left hand fingernails and stated the resident's nails needed to be cut and cleaned. She stated it was the responsibility of the nurses to cut fingernails and the responsibility of the CNAs to clean residents' hands and underneath her fingernails. She stated the risk of not trimming residents' fingernails was it could cause infections and skin breakdown if the hand was contracted. In an interview and observation on 04/17/25 at 1:00 PM, RN I stated she was the nurse assigned to Resident #20. RN I assisted Resident #20 with opening her left hand. RN I observed Resident #20's fingernails and stated her fingernails were long. Resident #20 asked RN I to please cut her fingernails. RN I stated Resident #20's fingernails were longer than Resident #5's. RN I stated it was the responsibility of the nurses and CNAs to cut fingernails and clean them. She stated the potential risk of not cutting fingernails was it could cause residents to scratch themselves and bacteria build-up. In an interview on 04/17/25 at 1:30 PM, the ADON stated the CNAs were responsible for cutting residents fingernails unless the residents were diabetic, then the nurses were responsible for cutting them. She stated if the residents refuse fingernails to be cut it should be documented and care planned. She stated Resident #5 had some fingernails she did not allow to be trimmed; however, staff should still ask them if she wanted them cut. She stated fingernails should be cleaned during showers or in between meals. She stated the potential risk of not cleaning, cutting, or trimming fingernails could lead to infections or skin tears. Interview on 04/17/25 at 2:28 PM, the Interim DON revealed the expectations were for CNAs to provide hand hygiene to residents during showers, before and after meals. She stated CNAs and Nurses should complete weekly skin assessments and need to ensure fingernails were clipped. She stated if residents refuse, it should be documented. She stated the potential risk of not cutting/trimming fingernails was it could cause skin breakdown if contracted or the resident could scratch themselves. 2. Record Review of Resident #34's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. The MDS reflected the resident's diagnoses included hemiplegia or hemiparesis (paralysis or weakness to one side of the body), chronic kidney disease, stage 3 unspecified (longstanding disease of the kidneys leading to renal failure), seizure disorder or epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), difficulty in walking, contracture left hand, and age-related physical debility. The MDS further reflected the resident had a BIMS of 10, meaning moderate cognitive impairment. The MDS also reflected Resident #34 required partial/moderate assistance (helper does less than half the effort and lifts, holds or supports trunk or limbs, but provides less than half the effort). Record review of Resident #34's care plan, revised on 02/11/25, reflected the following: Focus: Resident had an ADL self-care performance deficit relating to: mobility/hemiplegia, cognitive deficits, contracture. Goal: The resident will maintain current level of ADL abilities and will receive the necessary assistance to maintain a clean and neat appearance through the review date. Interventions: .Personal hygiene/oral care: the resident requires X1 staff participation with personal hygiene and oral care by CNA staff. In an observation and interview on 04/15/25 at 11:01 AM with Resident #34 revealed the resident had white build-up on her teeth, and it appeared her teeth had not been brushed. Resident #34 stated her teeth were last brushed about two weeks ago. Resident #34 said she would like her teeth brushed regularly. Resident #34 said she did not feel clean without her teeth brushed regularly. In an observation and interview on 04/16/25 at 1:44 PM with CNA A revealed Resident #34's teeth had not been brushed regularly. CNA A stated Resident #34's teeth appeared to not have been brushed that day, and she had not brushed them. CNA A said the residents' teeth were supposed to be brushed by the CNA when ADLs were performed each morning. CNA A revealed if a resident received poor oral hygiene, it could affect their self-esteem because they would have bad breath and would not want to be around other individuals. CNA A also revealed if a resident refused to have their teeth brushed, the CNA should report the refusal to their nurse. CNA A then stated if the nurse did not follow-up on the refusal, the CNA should report the refusal to the ADON. The CNA was not aware of the last in-service on ADLs because the CNA had been employed less than one month. Interview on 04/16/25 at 2:11 PM with LVN B revealed teeth should be brushed daily in the morning and in the evening before bed by anyone assisting the resident, but usually the Resident's CNA. LVN B stated if residents did not receive oral care regularly, residents could get infections, cavities, and lose weight because they could not chew. LVN B said if a resident refused oral care, the CNA should notify the resident's nurse. LVN B revealed the CNA should document the resident's refusal of oral care. LVN B stated the Resident's nurse should encourage and educate the resident on the importance of oral care. LVN B said if the resident continued refusing oral care, the nurse should notify the responsible party, the primary care physician, the ADON, and the DON. LVN B also stated the resident's care plan should be updated to reflect the resident's continued oral care refusal. LVN B said she was last in-serviced approximately one month ago. Interview on 04/17/25 at 10:02 AM with the ADON revealed the CNAs should perform oral care on residents daily when they dressed residents in the morning. The ADON stated if the resident refused, the CNA should attempt three times during their shift. The ADON continued and said if the resident still refused on the third attempt, the CNA should notify the nurse. The ADON revealed the nurse should attempt to discuss the reason for the refusal and accommodate the resident. The ADON stated if refusal continued, the nurse should notify the ADON, the DON, the Responsible Party, and the primary care physician. The ADON revealed poor oral care could lead to infections which could then lead to the resident not eating and possible weight loss. The ADON stated the staff were in-serviced on ADLs last month at the all-staff in-service. Interview on 04/17/25 at 10:16 AM with the Interim DON revealed that teeth brushing was part of the morning routine. The Interim DON stated oral care could be difficult for some residents with cognitive deficits. The Interim DON stated the CNAs should attempt oral care with residents once per day. The Interim DON said if the resident refused oral care by their CNA, the CNA should notify their charge nurse and document the refusal on the ADL sheet. The Interim DON revealed if the charge nurse did not follow up with the resident, the CNA should follow the chain of command until the resident's oral care was addressed. The Interim DON stated the nurse should contact the responsible party and notify them the resident was refusing oral care. The Interim DON stated the risk to the resident of not receiving proper oral care depended on the resident's cognitive status. Record review of the facility's current, undate Nail Care policy reflected the following: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. 1. Nail care will be performed regularly and safely. 2. The resident will free from abnormal nail conditions 3. The resident will be free from infection. Record review of the facility's Teeth Care/ Oral Hygiene policy, dated 06/29/05, reflected the following: .It includes procedures such as brushing and flossing, gum massage, and mouth rinsing. It is performed in the morning or at bedtime, and after meals depending on individual needs. The procedures can be done independently or with assistance in those with impaired ability to use the hands and arms. The resident will receive mouth care at lease daily. 48236

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #9 and #29) reviewed for quality of care. The facility failed to ensure Resident #9 and #29 wore their compression stockings, used to prevent swelling and blood clots, as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. Findings included: 1. Record review of Resident #9's quarterly MDS assessment, dated 03/27/25, revealed Resident #9 was an [AGE] year-old male with an admitted [DATE] and readmitted [DATE] with diagnoses which included edema and high blood pressure, and he had a BIMS score of 05, which indicated his cognition was severely impaired. Record review of Resident #9's care plan, dated 03/31/25, did not address edema and compression stockings. Record review of Resident #9's physician orders, dated 04/2/25, reflected: Compression stockings to BLE on am [morning] and off pm [evening] for edema. Observation and interview on 04/15/25 at 12:27 PM of Resident #9 revealed Resident #9 sitting on his chair. Resident #9's legs (lower extremities) were observed with edema and had no compression stocking. Resident #9 stated staff [NAME] the regular socks on him. Observation on 04/15/25 at 2:37 PM revealed Resident #9 wheeling himself in the hallway. The resident did not have the compression stockings on his legs. Observation and interview on 04/16/25 at 12:10 PM revealed Resident #9 was on his wheelchair in the hallway. Resident #9 stated he did not have any compression stockings on his legs. Resident #9 stated staff did not put the compression stockings on him. He could not recall the last time he had compression stocking on. 2. Record review of Resident #29's quarterly MDS assessment, dated 03/18/25, revealed Resident #29 was a [AGE] year-old male with an admitted [DATE] and readmitted [DATE] with diagnoses which included edema and cellulitis, and he had a BIMS score of 14, which indicated his cognition was Intact. Record review of Resident #29's care plan, dated 12/30/24, revealed Focus: Resident #29 was on diuretic therapy rule out bilateral lower extremities Edema. Goal: He will be free of any discomfort or adverse side effects of diuretic therapy through the next review date. Interventions: Administer medication as ordered. Record review of Resident #29's physician orders, dated 11/23/2023, reflected: Compression stockings to BLE on am and off pm for edema. Observation and interview on 04/15/25 at 11:35 AM of Resident #29 revealed Resident #29 sitting on his wheelchair in the dining area. Resident #29's legs (lower extremities) were observed with edema and had no compression stockings on. Resident #29 stated staff did not put compression stockings on him, and they only applied cream on his legs. Observation on 04/15/25 at 2:15 PM revealed Resident #29 in his room. The resident did not have the compression stockings on his legs. Observation and interview on 04/16/25 at 10:47 AM revealed Resident #29 was seated in his wheelchair in his room watching television. Resident #29 stated he did not have any compression stockings on his legs. Resident #9 stated staff did not put compression stockings on him. He could not recall the last time he had stockings on. Interview on 04/16/25 at 1:20 PM with CNA G revealed Residents #9 and #29 were her assigned residents. She stated she got report from the nurse when she reported on duty. She stated she was not aware Residents #9 and #29 were supposed to have compression stockings on both their legs. CNA G stated it was the nurse's responsibility to put on Resident #9 and #29's compression stockings. Interview on 04/16/25 at 1:33 PM with LVN D revealed she was the nurse for Resident #9 and #29. LVN D stated she worked the 6:00 AM-2:00 PM shift. LVN D stated Residents #9 and #29 had orders for compression stockings due to edema. She stated she was aware both residents were supposed to have compression stockings put on in the morning but every time she wanted to put the stockings on, something would distract her from getting the stockings from the central supply, since they did not have any in their rooms. LVN D stated the risk of not using the compression stockings as ordered could cause circulation issues and the edema would increase. She stated she had not done an in-service on compression stockings. Interview on 04/17/25 at 10:34 AM with the ADON revealed the nurses were responsible for putting compression stockings on residents and to follow physician orders. The ADON stated Residents #9 and #29 had orders for compression stockings due to their bilateral legs swelling. The ADON stated staff should be documenting on the MAR/TAR if residents refused treatment and when they had put compression stockings on and off. The ADON stated she had noticed Resident #9 and #29 without compression stockings on Monday 04/14/25, and she talked about it with LVN D. She stated LVN D notified her both residents did not have compression stockings in their rooms. LVN D did not know where to find the compression stockings in the central supply. The ADON stated she gave the nurse the compression stockings for both Residents #9 and #29, and she was not aware LVN D was not using them on Resident#9 and #29. The ADON stated the risk of not putting compression stockings on Resident #9 and #29 would be lack of circulation and increase in edema. She stated she had not done an in-service on compression stockings with staff. Interview on 04/17/25 at 10:34 AM with the Corporate Nurse, who was acting as Interim DON, revealed nurses were responsible for ensuring compression stockings were put on Residents #9 and #29 in the morning and off at night. She stated the nurse should not be signing off in the residents' EHRs that the compression stockings were on when they had not put the compression stockings on the residents. She stated failure to put compression stockings on Residents #9 and #29 would cause their edema to worsen. She stated they had not done an in-service on compression stockings, but they would be starting one. Record review of the facility's TED Hose [compression stockings] policy, dated 02/13/07, reflected the following: Antiembolism hose are elastic stockings (TEDS ) applied to an extremity to promote venous return and prevent pooling of blood in the leg(s). PURPOSE 1. To provide support for lower extremities. 2. To aid return circulation from lower extremities. 3. To prevent embolus formation. 4. To reduce pain. The facility did not have a specific policy related to following these physician orders.

Based on observations, interviews, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater, 3 errors of 33 opportunities for errors leading to 9.09% medication error rates, for two of four staff (LVN D and MA F) observed for medication pass. The facility failed to ensure MA F administered the correct dose of 500mgs vitamin B12 for Resident #19. The facility failed to ensure LVN D administered all the crushed medication in the medication cups without leaving residue for Resident #105. These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for tube occlusion, not receiving the correct dose of medication, and those that took orally not getting intended therapy. Findings included: 1. Record review of Resident #19's quarterly MDS Assessment, dated 03/26/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmission on 03/07/25. Her BIMS score was 11, revealing her cognition was moderately impaired. Her diagnoses included anemia (a condition where the blood doesn't have enough healthy red blood cells, or the red blood cells don't function properly, leading to a reduced ability to carry oxygen). Record review of Resident #19's care plan, dated 12/28/24, reflected the following: Focus: Resident #19 has anemia rule out vit B12 deficiency. Goal: Resident will remain free of complications related to anemia through review date. Interventions: Administer medications as ordered. Monitor for side effects, and effectiveness. Record review of Resident #19's April 2025 physician orders reflected the following: Cyanocobalamin Tablet 1000 Mcg. Give 0.5 tablet by mouth one time a day for Vitamin b 12 deficiency. Observation on 04/16/25 at 08:13 AM revealed MA F prepared the following medication: Cyanocobalamin Tablet 1000 MCG 1 tablet in a cup. She went to Resident#19's room and administered it to her. Interview on 04/16/25 at 10:46 AM with MA F revealed she was aware she was supposed to review Resident #19's physician orders prior to administering her medications. MA reviewed Resident #19's physician order and stated she was not aware the resident had an order to administer 0.5 tablet of 1000mcg and she has been administering 1000mcg daily. She stated the failure to administer the correct dosage to Resident #19 would lead to a medication error and not getting the right therapy. 2. Record review of Resident #105's admission MDS Assessment, dated 04/11/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE], her BIMS was not completed due to the resident was newly admitted . Her diagnoses included cerebral infarction (stroke), and gastrostomy status (surgical opening into the stomach). Record review of Resident #105's care plan, dated 04/14/25, reflected the following: Focus: Resident #105 requires tube feeding rule out Dysphagia (difficulty swallowing). Goal: Resident will remain free of side effects or complications related to tube feeding through the next review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #105's April 2025 physician orders reflected the following: - Enteral Feed Order every shift May crush meds or open capsules unless contraindicated. Do not mix together. - Enteral Feed Order every shift Flush enteral tube with 60ml water pre/post medication administration and 5-10 ml water between each medication. - Amlodipine Besylate Oral Tablet 5 MG. Give 5 mg via G-Tube one time a day related to essential (primary) hypertension Hold for SBP less than 115 and DPB less than 70. Start Date 04/12/25 - Ascorbic Acid Oral Tablet 500 MG Give 500 mg via G-Tube one time a day related to unspecified protein calorie malnutrition- start date 04/12/25. - Aspirin 81 Oral Tablet Chewable (Aspirin). Give 81 mg via G-Tube one time a day for preventive- Start Date 04/12/25. - Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) give 1 tablet via G-Tube one time a day for unspecified protein calorie malnutrition. -Metformin HCl Oral Tablet 500 MG. Give 500 mg via G-Tube two times a day for diabetes mellitus related to type 2 diabetes mellitus without complications. Observation on 04/16/25 at 08:33 AM revealed LVN D prepared the following medication, crushed them, and placed them in separate cups: - Vitamin C tablet 500mgs 1 tablet via g-tube - Aspirin 81mgs 1 tablet via g-tube - Amlodipine 5mgs 1 tablet via g-tube - Metformin 500mgs 1 tablet via g-tube - Multivitamin 1 tablet via -g-tube LVN D dissolved the medication prior to administering to Resident #105. LVN D went to Resident #105's room, positioned the resident, checked for the g-tube placement and residual, and flushed the g-tube with 10 ml of water. LVN D poured the crushed medication, each cup at a time and flush with 5-10mls of water. She then flushed with 20mls of water. Two cups were noted to have scanty medication residue remaining in the cups. Interview on 04/16/25 at 09:01 AM with LVN D revealed she did not review Resident #105's physician orders prior to administering her medications via gastronomy tubes. LVN D reviewed Resident #105's physician order and stated she was not aware the resident had an order to flush 60 ml of water before and after medication administration.Not considered because all was included on medication administration error . LVN D stated she did not flush the gastronomy tube with the prescribed amount. LVN D stated she was aware medication residual remained in the cups. She stated she was supposed to give all the contents in the cup for Resident #105 to get the full dose of those medications. She stated the failure to administer the full doses to Resident #105 would lead to the resident having not getting the therapy needed. Interview on 04/17/25 at 10:15 AM with the ADON revealed her expectation was with medication administration through the g-tube, nurses should try to give as much as possible of all the contents in the cups. She also stated the nurse should ensure they were flushing the gastronomy tube with the prescribed water to prevent gastronomy tubes from getting clogged. The ADON stated when administering medication. the nurses and the MA were expected to check the physician order before they pop the medications. She stated the failure to administer the full dose leads to resident medications not to be as effective and also the failure to administer the right dose would lead to overdose or a low dose and which could cause the medications to not be as effective. The ADON stated it was her responsibility to ensure the staff were doing the right thing, ensure the orders were in place for all the residents, and they were being followed. She stated the facility had done training of medication administration and g-tube medication administration. No training records were provided. Interview on 04/17/25 at 12:30 PM with the Interim DON revealed her expectation was with medication administration through the g-tube, nurses should try to give as much as possible of all the contents in the cups. The Interim DON stated when administering medication via g-tube, nurses were expected to check the order, and flush the g-tube with the right orders. The Interim DON stated the MA F was supposed to follow the physician orders. She stated the failure to administer the full dose would lead to resident medications not being effective. The Interim DON stated the failure to follow the physician orders could also lead to an overdose. The Interim DON stated it was the ADON's responsibility to ensure the staff were doing the right thing and ensure the orders were in place and being followed. Record review of the facility's Enteral Medication Administration policy, revised 01/25/13, reflected the following: 7. Flush the tube with 30ml water or according to physician order. 8. Administer one medication at a time with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the final medication is administered. Verify that medication cups are clear of any remnants of crushed pills or liquid medication. Alternate fluid may be used if the facility policy and diet orders permit. 9. Once all medications have been administered, flush the tube with 30ml water or according to physician order. Record review of the facility's Medication Administration Procedures policy, revised 10/25/17, reflected the following: 20. The 10 rights of medication should always be adhered to 1. Right patient 2. Right medication

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #34) reviewed for foot care. The facility failed to ensure foot care, specifically trimming of toenails, was provided for Resident #34. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Record review of Resident #34's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. The MDS reflected the resident's diagnoses included hemiplegia or hemiparesis (paralysis or weakness to one side of the body), chronic kidney disease, stage 3 unspecified (longstanding disease of the kidneys leading to renal failure), seizure disorder or epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), difficulty in walking, contracture left hand, and age-related physical debility. The MDS further reflected the resident had moderate cognitive impairment. The MDS also reflected Resident #34 required partial/moderate assistance (helper does less than half the effort and lifts, holds or supports trunk or limbs, but provides less than half the effort). Record review of Resident #34's care plan, revised on 02/11/25, reflected the following: Focus: Resident had an ADL self-care performance deficit relating to: mobility/hemiplegia, cognitive deficits, contracture to left hand. Goal: The resident will maintain current level of ADL abilities and will receive the necessary assistance to maintain a clean and neat appearance through the review date. Interventions: .Personal hygiene/oral care: the resident requires X1 staff participation with personal hygiene and oral care by CNA staff (toenail trimming was not addressed). Record review of Resident #34's Physician's Orders revealed Resident #34 had no referral to a podiatrist. Observation and interview on 04/15/25 at 11:01 AM with Resident #34 revealed she would like her toenails trimmed. Resident #34 stated no one had offered to trim her toenails since her re-admission on 09/18/24. Resident #34 said she had not asked a staff member to trim her toenails. The resident's toenails appeared approximately 1/4 of an inch long, clean, thin, needed to be trimmed. The resident did not express pain. Observation and interview on 04/16/25 at 1:44 PM with Resident #34 revealed the resident's toenails still had not been trimmed since 04/15/25 at 11:01 AM. Interview on 04/16/25 at 1:45 PM with CNA A revealed Resident #34's toenails needed to be trimmed. CNA A stated Resident #34 could scratch herself which could lead to an infection. CNA A said long toenails were painful. CNA A stated she had been employed at the facility approximately two weeks. CNA A revealed it was all staff's responsibility to trim toenails if the resident was not diabetic. CNA stated if a resident was diabetic, the nurse or physician should trim the resident's toenails. CNA A explained if the resident would not allow the aide to trim the toenails, the aide should report it to the nurse. CNA A stated toenails should be examined in the morning when completing ADLs. Interview on 04/16/25 at 2:01 PM with LVN B revealed it was the nurses' responsibility to trim toenails. And if a resident was diabetic, the nurse should not trim the resident's toenails and should ask the doctor for a referral to a podiatrist. LVN B stated it was the aide's responsibility to notify their nurse if a resident's toenails needed to be trimmed. LVN B said if a resident's toenails were too long, the toenail could snag on clothes, bedding, etc. resulting in injury or infection. LVN B revealed she was in-serviced within the last month on ADLs. Interview on 04/17/25 at 10:02 AM with the ADON revealed the CNA should notify the nurse if a resident's toenails should be trimmed. The ADON stated if the resident was diabetic, the nurse should notify the social worker to add the resident to the podiatry list. The ADON also revealed if the resident was not diabetic and refused to have their toenails trimmed, the nurse should also notify the social worker to add the resident to the podiatry list. The ADON said that if a resident continued to refuse toenail care, the resident's care plan would reflect the continued refusal. The ADON revealed residents could receive skin tears resulting in infection if the toenails were not kept trimmed. The ADON concluded by stating administration in-serviced all staff last month on ADLs. Interview on 04/17/25 at 10:16 AM with the Interim DON revealed a resident's aide should notify the nurse if a resident's toenails should be trimmed. The Interim DON also stated the wound care nurse upon weekly skin inspections should notify the nurse. The Interim DON said if a resident was diabetic or had thick toenails, the nurse should refer them to podiatry. The interim DON stated if the resident's toenails were thin and normal, the resident's nurse could trim them. The Interim DON explained the facility had to receive an order from the physician for the podiatrist and written approval by the responsible party before the resident could be seen by the podiatrist. Upon receipt of the written approval and referral, the Social Worker would put them on the podiatry list. The Interim DON stated there was not a big risk to the resident unless the resident was complaining of pain. Interview on 04/17/25 at 10:43 AM with the facility Social Worker revealed the nurse should obtain an order for the podiatrist if a resident had a cause to be seen by the podiatrist. The Social Worker stated she would next request permission from the family for the resident to be seen by the podiatrist. The Social Worker said Resident #34 was not on her podiatrist list and a referral had not been made. The Social Worker revealed the risk to the resident for untrimmed toenails was she was uncomfortable, they could catch on the sheets, etc. Record review of the facility's Foot Care policy, revised 2003, reflected the following: Foot management is the daily assessment, bathing, lubrication, and protection of the feet. It is done to promote cleanliness and peripheral circulation of the feet. Foot care is especially important in those residents with diabetes mellitus or peripheral circulatory conditions because of their susceptibility to infection and skin breakdown. If required, trimming of the toenails is performed by a podiatrist. Goals 1. The resident will maintain intact skin integrity. 2. The resident will be free from infection. 3. The resident will remain free from injury to the fact.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one of 18 residents (Resident #36) reviewed for resident rights. The facility failed to ensure Resident #36 was treated with dignity and respect when she asked CNA C to dress her. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/05/25 and ended on 03/06/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #36's Quarterly MDS Assessment, dated 04/2/25, reflected the resident was a [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE]. Resident #36's diagnoses of hemiplegia or hemiparesis (paralysis or weakness to one side of the body), diabetes mellitus (disease that results in too much blood sugar in the blood), cerebrovascular accident, transient ischemic attack, or stroke (damage to the brain from interruption of its blood supply). Resident #36 also had a BIMS score of fifteen meaning the resident was cognitively intact. Resident #36's Quarterly MDS Assessment reflected the resident required dependent assistance (helper does all of the effort and resident does none of the effort) with lower body dressing and substantial/maximal assistance (helper does more than half the effort) with upper body dressing. Record review of Resident #36's Care Plan, dated 03/31/25, reflected Resident #36 had an ADL self-care performance deficit and required assist with ADLs relating to impaired mobility/hemiplegia and cognitive deficits. Record review of Resident #36's Care Plan also reflected the resident will be provided assist with ADLs through the review date to maintain current ability and clean appearance. Resident #36's Care Plan Interventions reflected the resident was a two person staff participation to dress and to dress the resident according to resident comfort/season. Record review of the Provider Investigation Report dated 03/12/25 reflected, Upon review of video footage provided by resident's daughter, it was determined that the CNA did not act professionally. She was observed on video speaking unprofessionally and loudly to resident. The Provider Investigation Report also reflected that the Wound Care Nurse, .completed head to toe assessment with no negative findings. Resident denied any mental, physical or emotional abuse. No injuries noted. No changes in behavior noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA C was terminated. Record review of the Resident's Statement, dated 03/06/25, of the previous day's event, reflected that sometime before lunch, the resident asked CNA C to change her clothes and then she became irritated. CNA C was unclear why she acted that way. The resident stated she needed her shirt changed and her pajama pants put on so she could get up for lunch. The resident stated she told CNA C she was being bossy. The resident denied being fearful or scared but stated she did not like the way CNA C was speaking to her. The resident denied any mental, physical, or emotional abuse. The resident did, however, state she did not want CNA C to provide any further care to her. Record review of CNA's personnel file on 04/17/25 at 2:51 PM reflected CNA C was suspended on 03/06/25 and terminated on 03/07/25. Interview on 04/15/25 at 10:42 AM with Resident #36 revealed the resident, on 03/05/25, asked CNA C to assist her in dressing in pajama pants and a top so she could go to the dining room. Resident #36 said CNA C was very rude and disrespectful to her in her response and told her to put the pajama pants on herself twice. Resident #36 stated she did not feel CNA C was abusive, but she was verbally rude in her tone. Resident #36 also said the CNA did not physically harm her. Resident #36 concluded by stating she was never afraid, scared, or sad; she only felt disrespected by CNA C. The resident revealed she was not afraid of anyone in the facility, and she felt safe. Interview on 04/17/25 at 12:33 PM with the Wound Care Nurse revealed Resident #36 was not in fear or scared when she made her assessment, but the resident could have feelings of depression or isolation if CNA C continued providing care after the initial incident. She stated there was no skin breakage nor bruises. She stated the resident denied pain or soreness during the assessment. She said she had not heard of any abuse by the aide previous to this event. Interview on 04/17/25 at 12:45 PM with the ADON revealed the facility suspended CNA C immediately following the allegation of verbal abuse. The ADON also stated CNA C was later terminated at the conclusion of the investigation. The ADON revealed they educated staff on abuse/neglect. The ADON also stated the Social Worker completed safe surveys and determined no one else was verbally or physically abused. Interview on 04/17/25 at 12:40 PM with the Social Worker revealed the Resident's daughter called the Administrator and told her an Aide had verbally abused her mother. The Social Worker said she recalled Resident #36 stating CNA C was rude but was not physically abusive to her. The Social Worker could not recall further details about the incident. Interview on 04/17/25 at 4:32 PM with the Administrator revealed Resident #36's Responsible Party sent a video of an interaction with an aide and Resident #36 to the facility that she received. The Administrator stated she viewed the video and suspended CNA C based on a poor customer service tone. The Administrator revealed they later terminated CNA C based on the video viewed. The Administrator said the facility completed safe surveys, interviewed staff, and interviewed residents. The Administrator revealed the facility in-serviced the staff on abuse/neglect, customer service, and resident rights. Record review of the facility's Abuse/Neglect policy, revised on 09/09/24, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. The Incident/Accident log was reviewed with no issues noted. The Resident Council minutes were reviewed with no issues noted. Grievances were reviewed with no issues noted. Safe surveys were completed with eleven residents with no issues noted. An Ad Hoc QAPI was conducted with the recommended following items below completed during a 4-week period: Ask 15-20 staff members per week, situational questions related to abuse. Document date and time, the staff member's name, if they responded correctly, and any corrective action if needed. Ask about 5 residents per week how staff is treating them. Document date/time, the resident's name, if there was any negative response, and any corrective action if needed. During incident/event review in standup, the DON and the Admin will monitor for potential abuse in the event Reports. During facility rounds, there were not any signs of staff acting rudely or inappropriate with residents. Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: In-Service with staff on Abuse/Neglect on 03/05/25, Code of Conduct, Customer Service, and Resident Rights on 03/10/25 initiated from the Administrator to all facility staff and completed. Interview on 04/17/25 at 12:50 PM with MA F revealed she recalled the in-services given by the facility following the suspension of CNA C. MA F stated three types of abuse were physical, mental, and financial. MA F said three signs of abuse yelling, anger, and withdrawing from care. MA revealed she would report signs of abuse to the Administrator, the abuse coordinator. MA stated the facility was also in-serviced on abuse about two days ago. Interview on 04/17/25 at 2:32 PM with CNA H revealed she recalled the facility in-serviced all the staff on four topics including abuse/neglect, customer service, code of conduct, and resident rights. CNA H stated types of abuse were physical, mental, financial, and verbal. CNA H said three signs of abuse occurred when the resident avoided eye contact, bruises, and the resident withdrew from care. CNA H revealed she would report these and other signs to the Abuse Coordinator, the Administrator, immediately if she saw any of these signs. Interview on 04/17/25 at 2:40 PM with the Activity Aide revealed she knew three types of abuse were mental, physical, and financial. The Activity Aide stated three signs of abuse were bruises, behavior changes, and crying. The Activity Aide said that she would report signs of abuse to the abuse coordinator, the Administrator as soon as she was made aware of an abuse allegation. Interview on 04/17/25 at 2:56 PM with LVN D revealed she recalled the in-service on abuse. LVN D stated types of abuse were physical, sexual, financial, and verbal. LVN D also said that bruises, changes in behaviors, and refusal of care were types of abuse. LVN D stated that she would report any type of abuse or abuse allegation to the Administrator, the abuse coordinator immediately. LVN D said that she was in-serviced on abuse about a week ago. Interview on 04/17/25 at 3:23 PM with CNA E revealed she was in-serviced on all four in-services immediately following CNA's C suspension. CNA E stated she had been employed at the facility for approximately three years. CNA E also said that three types of abuse were verbal, sexual, and neglect. CNA E stated that three signs of abuse were bruises, skin tears, and crying. CNA E revealed that she would report any signs of abuse or allegations of abuse to the abuse coordinator, the Administrator immediately. CNA E stated she was in-serviced on abuse yesterday also. Interview on 04/17/25 at 3:14 PM with RN I revealed she recalled being in-serviced on a group of topics the first week of March. RN I stated three types of abuses are physical, sexual, and verbal. RN I said that signs of abuse could be bruising, scratches and anger. RN I stated she would report any signs of abuse to the abuse Administrator and the DON. RN I concluded by stating she was in-serviced last month on abuse. Interview on 04/17/25 at 4:32 PM with the Administrator revealed Resident #36's Responsible Party notified her a staff member verbally abused her mother, and she had it on video. The Administrator received the video the following day and viewed it. The Administrator interviewed Resident #36, and Resident #36 stated CNA C was bossy, but was not fearful. The Administrator said she suspended the staff member immediately. The Administrator revealed she believed CNA C gave poor customer service based on her tone and it was inappropriate, and therefore terminated her employment. The Administrator stated the facility completed safe surveys, interviewed staff, and interviewed residents. The Administrator revealed she in-serviced the staff on abuse/neglect, customer service, code of conduct, and resident rights as well.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 1 (Resident ##9) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #9's compression stockings. This failure placed resident at risk of not receiving appropriate care. Findings included: Record review of Resident #9's quarterly MDS assessment, dated 03/27/25, revealed Resident #9 was an [AGE] year-old male with an admitted [DATE] and readmitted [DATE] with diagnoses which included edema and high blood pressure, and he had a BIMS score of 05, which indicated his cognition was severely impaired. Record review of Resident #9's care plan, dated 03/31/25, did not address edema and compression stockings. Interview on 04/17/25 at 10:34 AM with the ADON revealed Resident #9 was supposed to be care planned for edema and compression stockings. She stated it was her responsibility and the DON's to update the care plan when they received a new order, but she missed the orders. She stated failure to update or have a care plan would lead to not taking the appropriate measures to address the edema and risk of fluid overload. Interview on 04/17/25 at 12:47 PM with the Corporate Nurse who was acting as Interim DON, she stated it was the responsibility of the nursing management team to care plan for edema and compression stockings. She stated she noticed there was no care plan for Resident#9's compression stockings and edema, and she would update the care plan. She stated she did not see any risk if the care plan was not updated as long as the nurses were following the doctor's orders. Review of the facility's current, undated, Comprehensive Care Planning policy reflected the following: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #105) reviewed for intravenous fluids. The facility failed to ensure Resident #105's intravenous tubing was labeled with the date and initials. The failures could affect residents by placing them at risk for infections. Findings included: Record review of Resident #105's admission MDS Assessment, dated 04/11/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS was not completed due to resident was newly admitted . Her diagnoses included cerebral infarction (stroke), and gastrostomy status (surgical opening into the stomach). Record review of Resident #105's care plan, dated 04/14/25, reflected the following: Focus: Resident #105 has potential fluid deficit rule out Dysphagia (difficulty swallowing) and g-tube status. Goal: Resident will be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor through the next review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #105's April 2025 physician orders dated 04/14/25 and 04/15/25 reflected the following: Sodium Chloride Intravenous Solution 0.45 % (Sodium Chloride) Use 80 ml/hr. intravenously one time a day for Increased Sodium Level until 04/15/2025 17:30 2nd bag 80ml/hr. x 13 hours total of 1000ml. Sodium Chloride Intravenous Solution 0.45 % (Sodium Chloride) Use 80 ml/hr. intravenously one time a day for Increased Sodium Level until 04/15/2025 04:00 80ml/hr. x 13 hours total 1000ml. Observation on 04/14/25 at 10:25 AM revealed Resident #105 was in her room, lying in bed. She was observed to have a PICC line dressing dated 04/12/25 and was intact. The intravenous medication bottle was hanging on the pole. The IV tubing was not labeled with the date, time, and initials to indicate when it was last changed. Observation and interview on 04/15/25 at 12:09 PM with LVN D revealed the IV tubing was supposed to have the correct, date, and initials of the nurse administering the medications. She stated she was not the one that hung the bag, she came on for the 6-2 shift. She was aware she was supposed to check whether the tubing was labeled because the tubing was good for only 24 hours, but she missed checking when taking over the shift. She stated the failure to label the tubing could lead to infection. LVN D stated she had had done training on intravenous medication administration. IV certification dated 1/06/25 was provided. Interview on 04/17/25 at 10:46 AM with the ADON revealed she expected staff to date and initial tubing when administering intravenous medications or fluids. She also expected staff to check on all equipment's status when taking over a shift. She stated she had also checked on 04/15/25 and noticed the tubing was not labeled. She stated it was the responsibility of the DON and the ADON to check after the nurses and ensure IV bags and tubing were labeled with date, time, and initials. She stated tubing was good for 24 hours. She stated the failure to label the tubing put residents at risk for infection and if the tubing was used for more than 24 hours it affected the flow rate by making it slow and the resident might not get the expected therapy. She stated she had done training with staff on intravenous therapy. No training records were provided. Interview on 04/17/25 at 12:53 PM with the Interim DON revealed she expected staff to date and initial intravenous bags and tubing when administering intravenous to prevent infection. She stated it was the responsibility of the DON and the ADON to check after the nurses and ensure labelling was being done. She stated the facility had done training with staff on intravenous therapy. Interview on 04/15/25 at 12:09 PM with LVN E revealed she was the nurse that hung the IV fluids. She stated she was aware she was supposed to date and initial the bag and the tubing, but she forgot since the fluids were supposed to run for 48 hrs. She stated the tubing was good for 24 hours. She stated the failure to label the tubing could lead to infection. LVN E stated she had had done training on intravenous medication administration. Record review of the facility's training records reflected LVN D was IV certified. Review of the facility's current, Intravenous fluid management policy dated 2003, reflected the following: .2. Label the bag or bottle and IV line using tape, as the ink can absorb into the solution. On the label list the date that it was placed into use as well as the nurse's initials

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents (Resident #10) on one hall reviewed for storage of medications. The facility failed to ensure an Amoxicillin tablet (an antibiotic) was not left at Resident #10's bed side unsupervised on 04/15/25. This failure could place residents at risk of consuming unsafe medications. Findings included: Record review of Resident #10's face sheet, dated 04/17/25, revealed the resident was a [AGE] year-old male with an admitted [DATE] and readmitted on [DATE]. Record review of Resident #10's annual MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, depression, essential hypertension, and acute respiratory failure with hypoxia. Resident #10's BIMS score was 15 which indicated cognition was intact. Record review of Resident #10's physician order dated 04/11/25, revealed he had an order for Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet by mouth every 12 hours for UTI for 10 Days. Observation and interview on 04/15/25 at 10:56 AM revealed Resident #10 was in his room, on his bed. There was a clear cup on the bedside table with 1 tablet in it. Resident #10 stated the nurse dropped it off not long ago, he stated he was going to take it but fell asleep. Resident #10 stated the nurse dropped it off about 15-20 minutes ago, he stated he could not recall the nurse's name. Observation and interview on 04/15/25 at 11:08 AM with LVN D revealed she was the nurse assigned to Resident #10. LVN D observed the medication on Resident #10's bedside table. She stated it was his amoxicillin medication. LVN D stated she provided the medication about 5 minutes ago. LVN D stated she had to step out to assist staff with another resident and she was supposed to come back to the room. She stated the risk of leaving medication unattended was it could cause another resident to take it. Interview on 04/17/25 at 11:28 AM with the ADON revealed her expectations were for the nurses to follow physician orders and to see the residents take their medications before they left the room. She said she was informed Resident #10 had a pill on his bedside table. The ADON stated LVN D made a mistake by leaving the medications in the room. She stated the risk of leaving medication in rooms could lead to another resident taking it or the resident not taking the medication. Record review of facility's Medication Administration Procedures policy, dated 10/25/17, revealed the following: 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to be poured, administered, and charted by the same licensed person.

Based on observation, interview, and record review, the facility failed to ensure maintain medical records on each resident that are complete and accurately documented for 1 of 1 residents (Resident #105) reviewed for respiratory care. The facility failed to document on Resident #105's MAR/TAR showing that the resident's oxygen tubing was changed on Sunday as ordered by the physician. This failure could affect residents with respiratory therapy and could lead them to lack of care including possible infection by not following the physician orders. Findings included: Record review of Resident #105's admission MDS Assessment, dated 04/11/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE], her BIMS was not completed due to resident was newly admitted . Her diagnoses included cerebral infarction (stroke), and tracheostomy status (a surgical procedure where an opening is created in the trachea to allow for breathing). Record review of Resident #105's care plan, dated 04/14/25, reflected the following: Focus: Resident #105 requires has Tracheostomy rule out impaired gas exchange. Goal: Resident will have clear and equal breath sounds bilaterally through the review. The resident will have no signs and symptom of infection through the review date. Interventions: tube out procedures: Keep extra trach tube at bedside. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. notify emergency services immediately. Record review of Resident #105's April 2025 physician orders dated 4/14/25 reflected the following: Change all disposable respiratory tubing and equipment every week and as needed every night shift every Sunday. Review of the April 2025 Medication administration record had no documentation on when the disposable respiratory tubes were last changed. Observation on 04/15/25 at 10:18 AM revealed Resident #105 was receiving oxygen 3 liters per minute by oxygen mask in her room. She was using oxygen continually, and the tubing between the humidifier bottle and an oxygen concentrator, and to the compressor was not labelled. Observation and interview on 04/15/25 at 12:08 PM revealed the Respiratory Therapist and the ADON performing tracheostomy care to Resident #105.The Respiratory Therapist stated staff were supposed to label all the tubing since Resident #105 was admitted on [DATE]. She stated when Resident #105 was admitted , the admitting nurse called her, and they connected Resident #105's tracheostomy tubes and she thought she forgot to tell them to label it. She stated the oxygen tubing was supposed to be labeled so nurses were aware of when they were last changed and when to replace with new ones. She stated the failure to change the tubing put Resident #105 at risk for infection. She stated she did train all nurses before Resident #105 was admitted to the facility and no training records were provided. Interview and observation on 04/15/25 at 12:09 PM with LVN D stated Resident #105's disposable respiratory tubing and equipment were supposed to be labeled by the nurse that admitted Resident #105 on 04/11/25. She stated she was supposed to check the tubing for labelling every shift, but she did not check. Further interview, LVN-D said nurses should have changed all oxygen tubing and the humidifier bottle once a week every Sunday per the physician's order. She did not know what reason the nurses did not follow the order or document on the nurses' treatment administration record. She stated she had done training with the Respiratory Therapist before Resident#105 was admitted and she had been coming to monitor staff perform care. Certification of completion of respiratory /tracheostomy training dated 12/30/24 was provided. Interview on 04/17/25 at 10:38 AM with the ADON revealed, her expectation was nurses should change Resident #105's disposable respiratory tubing once a week every Sunday as per the physician's order to prevent possible respiratory infection and they should label them with the date when last changed. She stated she had seen Resident #105 on 4/14/25 and 4/15/25 and she did not notice the tubing was not dated. She stated before Resident #105 was admitted , the facility did classes and check offs with nurses and no record was provided. She stated the importance of putting the date on tubing was staff would be able to tell when it was last changed and when it needed to be changed again. She stated the failure to put dates when tubing was changed predisposes Resident#105 to infection because the moisture in the tubes harbored bacteria. Interview on 04/17/25 at 01:00 PM with the Interim DON revealed her expectation was nurses to follow orders and put dates when tubing was changed. She stated she had done training to all staff a year ago and she was not sure of current trainings on tracheostomy care. Interview on 04/17/25 at 02:51 PM with LVN E revealed Resident #105 admitted on [DATE] during her shift. She stated she connected her with the disposable respiratory tubing with the Respiratory Therapist on a video call. She stated she knew she was supposed to date the oxygen humidifier bottle and the disposable respiratory tubing on 04/11/25 but she forgot. She stated she did not see the need of putting the dates and the tubing was supposed to be changed again on Sunday as per the physician orders. She stated the failure to put the dates exposed the resident to infection because the nurse would not be able to tell when the tubing was last changed. She stated she had done training on tracheostomy care. Record review of the facility policy, titled Tracheostomy Care Procedure, revised 10/19/09, revealed did not address the disposable respiratory tubing.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, or misappropriation of resident property for 1 of 3 residents (Resident #1) reviewed for abuse. CNA A was witnessed to have spoken in a verbally abusive manner about Resident #1 This failure could cause residents to have decreased feelings of self-worth. The noncompliance was identified as past noncompliance that began on 07/10/24 and ended on 07/10/24. The facility had corrected the noncompliance before the state surveyor entered. No plan of correction needed. Findings included: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the left side of her body, diabetes, morbid obesity, and need for assistance with personal care. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, indicating she was cognitively intact. Her Functional Assessment indicated she was totally dependent on staff for all of her ADLs except eating. Record review of Resident #1's care plan, dated 12/30/24, reflected she had left sided paralysis related to her stroke, with interventions to assist with ADLs and mobility as needed. She was at risk for pressure ulcers related to her paralysis and obesity, with interventions of repositioning as needed, and using a pressure relieving mattress. Resident #1 had bowel and bladder incontinence related to paralysis, with interventions of providing incontinence care as needed. Record review on 02/25/25 at 8:30 AM of a video submitted by Resident #1's family member, dated 07/10/24, revealed CNA A can be observed walking away from Resident #1 to the doorway of the room and talking very loudly to someone in the hallway, saying If somebody don't come in here with me, right hand to God. She keeps pushing back on my hand and I already got a bad hand [NAME]. She gonna make me flip her ass out of this bed. She's gonna piss me off. Record review of the BOM's undated written statement reflected: On 7/10/24 around lunch time I was in my office when I heard some yelling in the hallway. Through my door I witnessed [CNA A] saying It's really pissing me off. I swear on everything, someone come help me cause she about to make me flip her ass out of the bed. Upon hearing this, I immediately exited my office and confronted [CNA A] in the hall. I told her she did not need to speak that way or say those things ever. She voiced her frustration about struggling to change the resident independently. I told her I understood but her behavior and verbiage was unacceptable and not tolerated and that she needed to calm down and ask for a patient change or some assistance from another CNA. After this conversation I immediately notified [the DON] and [Administrator] of what occurred in the hallway and the conversation that took place. Record review of CNA B's written statement, dated 07/11/24, reflected: So on 7.10.24 about 11:45 am I witnessed [CNA A] come out into the hall asking for help, she seemed agitated so I asked her what was wrong when she started to explain she was a little loud but she talks loud normally, so she stated can you come help with [Resident #1] before she make me flip her out the bed. She did not mean it in a way like intentional, she meant it accidentally because [Resident #1] do push back while trying to change her, she stated her wrist was hurting and that she needed help. I never witnessed her being verbally abusive towards [Resident #1], only the fact she was loud but it was not in [Resident #1's] room she was out in the hall talking to me. Record review of the facility's Provider Investigation Report, completed by the Administrator on 07/17/24, reflected Resident #1's family member called the DON to report that she had viewed on the camera in Resident #1's room, a CNA cursing, using profanity, and arguing with Resident #1 while providing the resident with care. Following the report, Resident #1 was assessed and found to have no mental anguish or injuries. The report reflected CNA A was suspended pending investigation, staff were re-educated on abuse and neglect, and safe surveys were completed. The report further reflected: Upon review of video footage provided by resident's [family member], it was determined that [CNA A] did not act professionally. She was observed standing in [the] doorway of [the] residents [sic] room talking loudly into [the] hallway. [CNA A] stated 'somebody gotta come in here with me, right hand of God. She keeps pushing back on my hand. I already have a bad hand [NAME]. She gonna make me flip her ass out this bed. She gonna piss me off.' She was not speaking directly to [the] resident but was in ear shot of [the] resident. The report concluded withe facility terminating CNA A's employment. Record review of the Inservice Training Report, dated 07/10/24, reflected facility staff were trained by the Administrator on Abuse and Neglect. Record review of Safe Surveys completed following the incident reflected no residents complained of abuse. Record review of the facility's Employee Disciplinary Report, dated 07/12/24, reflected CNA A's employment was terminated due to allegations of her verbally abusing a resident being substantiated. The report reflected: [CNA A's] actions were in violation of the Corporate Code of Conduct by violating the Resident's Rights and failing to carry out her duties/responsibilities and or performing work of substandard quality/quantity. Interview attempts on 02/25/25 at 9:00 AM and 1:55 PM with CNA A were unsuccessful. The message on CNA A's phone service reflected she was not taking phone calls at this time and did not allow for a voicemail message to be left. Interview on 02/25/25 at 9:10 AM with Resident #1 revealed she recalled the event. She stated she did not remember why CNA A was mad at her, but she stated when she overheard the CNA yelling in the hallway she was very upset. She stated CNA A was always yelling at her, saying the resident was going to have to do things the CNA's way. Resident #1 stated she was embarrassed and upset about the situation. Interview on 02/25/25 at 1:30 PM with CNA B revealed she verified her written statement taken during the facility investigation was true and accurate. CNA B stated Resident #1 could be difficult to work with. When she was turned to the left, instead of grabbing onto her bed rail and pulling, she would use it to push back against the caregivers. As a result, Resident #1 was now a two person assist for incontinence care. CNA B stated residents could be embarrassed by that kind of behavior. CNA B stated she had been in-serviced by the DON immediately after the incident on abuse and neglect. She was able to identify several types of abuse, and who to notify if she withnessed any abuse. Interview on 02/25/25 at 1:43 PM with the BOM revealed she verified her written statement taken during the facility's investigation was true and accurate. The BOM stated she was in her office at the end of the 200 Hall with the door closed when she heard a loud voice in the hallway. She stepped out and observed CNA A talking very loudly and inappropriately. The BOM stated she calmed CNA A down, after she determine what CNA A was upset about she told CNA A her language was inappropriate in a professional setting, especially when residents could hear her. The BOM notified the Administrator, and turned the situation over to her. The BOM stated she had been included in the in-service conducted by the DON immediately after the incident on abuse and neglect. She was able to verbalized several types of abuse and that she wasto notify the Administrator if she witnessed any abuse. Interview on 02/25/25 at 2:58 PM with the Administrator revealed CNA A was suspended immediately until an investigation could be completed. The Administrator stated she contacted the resident's family, and the family member of Resident #1 advised she had video footage of the incident. After reviewing the video footage and conducting interviews with staff, the Administrator terminated CNA A. The Administrator stated all residents deserve to be treated with respect and dignity, any form of abuse would not be tolerated. She stated this behavior could affect residents emotional health by causing them embarrassment. The Administrator stated the DON had immediately in-serviced staff on abuse and neglect. The Social Worker conducted Safety Surveys with residents of the hall, residents reported feeling safe with staff. Record review of the facility's Abuse/Neglect policy, revised 09/09/24, reflected: .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. .3. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Residents #6, #8, and #9) reviewed for quality of care. 1. The facility failed to ensure Resident #6, Resident #8, and Resident #9 had an indwelling urinary catheter strap in place to prevent pulling or tugging on 09/22/24. 2. The facility failed to provide Resident #6, Resident #8, and Resident #9 a privacy cover for the indwelling urinary catheter drainage bags on 09/22/24. 3. The facility failed to ensure Resident #8's indwelling urinary catheter was kept off the floor on 09/22/24. These failures could place residents at risk for discomfort, urethral trauma, loss of dignity and urinary tract infections. Findings included: RESIDENT #6 A record review of Resident #6's Quarterly MDS Assessment, dated 8/19/24, revealed a [AGE] year-old male who admitted on [DATE]. Resident #6 had a history and diagnoses of CKD, uns. (kidneys have mild to moderate damage) and severe sepsis secondary to UTI, uns. (a bacterial infection that occurs when bacteria enter the urethra [the hollow tube that lets urine leave the body] and infect the urinary tract). A BIMS score of 12 suggested Resident #6 had a moderate cognitive decline. Resident #6 had a suprapubic catheter ([SPC] placed 07/19/24) and was frequently incontinent of bowel. A record review of Resident #6's comprehensive care plan, initiated 03/30/23, next review date 11/06/24, reflected: [Resident #6] has a suprapubic catheter r/t obstructive uropathy and urinary retention (Initiated: 03/30/23; Revision: 09/06/24). Interventions included . position catheter bag and tubing below the level of the bladder and in a privacy bag (Initiated: 09/01/2024; Revision: 09/06/24); ensure catheter strap in place and holding so that tubing is not pulling on the urethra (Initiated: 07/25/23; Revision: 08/09/23); and ensure foley bag is in privacy bag while in wheelchair (Initiated 07/25/23). A record review of Resident #6's Order Summary Report printed 09/21/24 reflected: Order date 12/12/20: Ensure foley bag was in privacy bag while in bed or wheelchair. Order date 06/07/22: Ensure catheter strap in place and holding every shift. Order date 09/03/24: Cleanse suprapubic insertion site with normal saline, pat dry then cover with split 4 x 4 gauze dressing daily/PRN soilage/dislodgement. Order date 09/04/24: UA with C&S one time only for UTI. Order date 09/06/24: suprapubic catheter insertion site culture. One time only for yellow drainage from suprapubic site. Order date 09/09/24: Cephalexin oral capsule 500 mg. Give 500 mg by mouth every 12 hours for UTI until 09/19/24. Record review of Resident #6's September 2024 TAR revealed the orders were implemented as written and the Cephalexin 500 mg antibiotic treatment for UTI was completed on 09/19/24. During an observation and interview on 09/22/24 at 1:57 PM, Resident #6 was in a semi-side-lying (left lateral and back) position in bed. Resident #6 had a SPC in place at the lower midline abdominal area below the belly button and above the pubic bone. A 4 x 4 split gauze was secured over the SPC insert site. There was no indwelling urinary catheter strap in place to prevent pulling or tugging. The SPC tubing laid across Resident #9's right leg connected to a closed system drainage bag that hung on the bed rail. The drainage bag did not have a privacy cover. Resident #9 willingly participated in an interview. Resident #9 was pleasant and cooperative with direct care staff. Resident #9 was alert and oriented to person, place, time of day, and situation. Resident #9 said that the SPC was placed about 2 months ago. Resident #9 said that he used to have an indwelling urinary catheter that was inserted into the urethra (the duct by which urine is conveyed out of the body from the bladder). Resident #9 said that he just finished antibiotics for an UTI a couple days ago (record review indicated Thursday, 09/19/24). Resident #9 said that the nurse came in every morning to clean around his stomach (the SPC insert site) and placed a new dressing over it. Resident #9 denied pain or discomfort at the SPC insert site or symptoms of an UTI. RESIDENT #8 A record review of Resident #8's Entry MDS Assessment, dated 09/06/24, revealed a [AGE] year-old male readmitted on [DATE]. Resident #8 had diagnoses of Bladder Diverticulum (a thin-walled pouch that protrudes from the bladder wall); Retention of Urine; and Pressure Ulcer of Sacral region. Resident #8 had an indwelling urinary catheter and was incontinent of bowel. A record review of Resident #8's comprehensive care plan, initiated 08/12/24 to present, reflected: [Resident #8] has indwelling catheter to promote wound healing (Initiated: 08/12/24; Revision: 09/18/24). Interventions included . position catheter bag and tubing below the level of the bladder and in a privacy bag (Initiated: 08/12/2024; Revision: 09/18/24) and ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra (Initiated: 08/12/24; Revision: 09/18/24). A record review of Resident #8's Order Summary Report printed 09/21/24 reflected: Order date 09/07/24: Ensure foley bag was in privacy bag while in bed or wheelchair. Order date 09/07/24: Ensure catheter strap in place and holding every shift. Every shift change and as needed. Order date 09/07/24: Provide catheter care every shift. Record review of Resident #8's September 2024 TAR revealed the orders were implemented as written. During an observation on 09/22/24 at 2:29 PM, Resident #8 appeared to be asleep in a supine (on back) position in bed. Resident #8 did not have a catheter strap in place to prevent pulling or tugging. Resident #8's drainage bag did not have a privacy cover and the drainage bag rested on the floor beside the bed. RESIDENT #9 A record review of Resident #9's Admission MDS Assessment, dated 8/01/24, revealed a [AGE] year-old male who admitted on [DATE]. Resident #9 had a history and diagnoses of paraplegia with contractures; Neuromuscular dysfunction of Bladder, uns.; UTI; and Candida Auris ([MDRO] a multidrug-resistant organism). A BIMS score of 15 suggested Resident #9 was cognitively intact. Resident #9 had a right- and left-side percutaneous nephrostomy ([PCN] a tube that lets urine drain from the kidney through an opening in the skin on the back), an indwelling urinary catheter, and was frequently incontinent of bowel. A record review of Resident #9's comprehensive care plan, initiated 07/26/24, reflected: [Resident #9] has bladder incontinence (Initiated: 07/26/24). Interventions included Incontinent care at least every 2 hours and apply moisture barrier after each episode. (Initiated 07/26/24; Revision: 08/13/24); Monitor/document for s/sx UTI. [Resident #9] has Urinary Tract Infection (Initiated: 09/06/24; Revision: 09/10/24). Interventions included Give antibiotic therapy as ordered and provide incontinence care as needed. The care plan did not reflect a focus or interventions for percutaneous nephrostomies or indwelling urinary catheter. A record review of Resident #9's Order Summary Report printed 09/21/24, reflected in part: Start date 07/25/24, Empty nephrostomy drainage bag bilateral; Empty the left and right nephrostomy tube and enter the output every shift; Enhanced Barrier Precautions every shift; Ensure catheter strap in place and holding every shift change as needed; Ensure foley bag is in privacy bag while in bed or wheelchair every shift; Provide catheter care; and Foley urinary catheter 16 FR/10 mL to gravity drainage every shift. Record review of Resident #9's September 2024 TAR revealed the orders were implemented as written and Ciprofloxacin 500 mg antibiotic treatment for UTI was completed on 09/17/24. During an observation and interview on 09/22/24 at 2:30 PM, Resident #9 was sitting up in bed. Resident #9 had an indwelling urinary catheter in place. There was no indwelling urinary catheter strap in place to prevent pulling or tugging. The catheter tubing laid across Resident #9's right leg connected to a closed system drainage bag that hung on the bed rail. The drainage bag did not have a privacy cover. Resident #9 was pleasant and willingly participated in an interview. Resident #9 was alert and oriented to person, place, time of day, and situation. Resident #9 said that he had nephrostomy tubes to his right and left kidney. Resident #9 said that he also had an indwelling urinary catheter inserted into the urethra (the duct by which urine is conveyed out of the body from the bladder). Resident #9 said that he had a follow up appointment with his urologist in October. Resident #9 said that the staff never placed a strap to prevent the catheter tubing from getting pulled or tugged. Resident #9 said that he just finished antibiotics for an UTI a few days ago (record review indicated Tuesday, 09/17/24). Resident #9 said that the nurse provided catheter care every morning and the CNAs emptied the drainage bag before the shift change. Resident #9 denied pain or discomfort at the SPC insert site or symptoms of an UTI. During an interview on 09/22/24 at 2:39 PM, CNA E said that she reviewed facility training videos on catheter care and it had been covered during in-services. CNA E said that she would empty the drainage bag when providing peri-care to a resident and would report how much, if the urine had an odor, and if dark in color because of a possible UTI to the nurse. CNA E said that there should be a blue cover on the catheter drainage bags for privacy and dignity. CNA E said it was the nurse and the CNAs responsibility to ensure a privacy cover was on the drainage bags. CNA E could not explain why Residents #6, #8, and #9 did not have privacy covers or why she did not retrieve a privacy cover and place on the drainage bag. During an interview on 09/22/24 at 3:15 PM, LVN B said she worked weekend double shifts (6A -2P; 2P - 10P). LVN B said she provided catheter care based upon standards of practice, physician orders, and the care plan. LVN B said that she was observed for catheter care competency during new hire training and orientation. LVN B said that she checked for placement, for signs of infection such as redness, discharge, or swelling at insert site, and urine characteristics when she provided catheter care daily. LVN B said residents with catheters should have a leg support strap in place to prevent trauma or the catheter tubing from being pulled out. LVN B said that catheter drainage bags should have a privacy cover. LVN B could not explain why Resident's #6, #8, and #9 did not have a catheter stabilization device in place or a privacy cover on the drainage bag. LVN B said that all direct care staff were responsible for making sure a privacy cover was on the catheter drainage bag. LVN B said that she was the primary responsible person when assigned to the resident. LVN B said that she would place privacy covers on the drainage bags and ensure a leg support strap was in place. LVN B said that Resident #8's drainage bag probably rested on the floor because [Resident #8] bed must remain in the lowest position when in bed. Walking rounds revealed LVN B followed through with privacy covers and stabilization devices were in place and Resident #8's bed was raised slightly enough to prevent the catheter bag from resting on the floor. During an interview on 09/22/24 at 4:00 PM, the DON said that the implementation of care plan interventions was reviewed every morning during the clinical meeting. The DON said that a preceptor observed and monitored nurses for competency skills and would sign off on the competency skills check off when successfully met. The DON said that nurses who were successfully checked off for catheter care competencies and skill sets were allowed to insert, provide care for, and remove indwelling urinary catheters. The DON said that nephrostomy tube care should be included in nurse competency skills checkoffs but was not sure. The DON said that she was employed for less than 3 months and was not familiar with all the trainings provided to nurses. The DON said that residents were assessed and evaluated if indwelling catheters were clinically indicated. The status of residents' catheter needs was discussed during IDT meetings. The DON said that Resident #6 and Resident #9 had a history of recurring, persistent, or chronic UTIs related to their kidney functions. The DON said that interventions in place for residents with indwelling catheters included water intake, supplements, and catheter care every shift. The DON indicated that residents were at risk of UTI development if the catheter was not changed or managed appropriately. During an interview on 09/22/24 at 5:50 PM, the NFA provided procedures related to catheter insertion. The NFA could not provide a specific policy and procedure related to catheter care. The NFA said that catheter drainage bags should have a privacy cover always applied for resident's dignity; should never be placed on the floor and must remain below the bladder to prevent the backflow of urine into the bladder, which could cause an infection. A specific policy about Catheter Care and Maintenance was requested from the NFA on 09/22/24 at 3:54 PM. A policy on indwelling catheter insertion was provided. The NFA did not have a specific policy as requested. Record review of Catheter Care and Maintenance (2017) reviewed the DO's and DON'Ts of indwelling urinary catheter care and maintenance. The Agency for Healthcare Research and Quality (AHRQ) outlined strategies to prevent catheter-associated urinary tract infections. Guidelines reflect stabilization of the catheter tubing with a special fastening device; keep the drainage bag below level of bladder to drain urine by gravity; and always keep the drainage bag off the floor to keep the catheter clean and free of germs. Catheter Care and Maintenance. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-care/slides.html

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Residents #1, #6, and #7) reviewed for quality of care, in that: 1. The facility failed to prevent Resident #1's wound from increasing in size. Resident #1's Stage 3 coccyx wound measured 5 cm x 1.5 cm x 0.1 cm on 09/03/24 and increased in size to 12 cm x 10 cm x 0.1 cm when last seen by the WMD on 09/10/24. 2. The facility failed to ensure that Resident #6's low air loss mattress pump was plugged in. 3. The facility failed to ensure that Resident #7's low air loss mattress pump had the correct settings. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: RESIDENT #1 A record review of Resident #1's Quarterly MDS Assessment, dated 08/25/24, revealed a [AGE] year-old female who admitted on [DATE]. Resident #1 had a history and diagnoses of Cerebral Infarction, uns. ([ischemic stroke] is when there's some kind of blockage that keeps blood from reaching all areas of the brain); T2DM (a chronic condition that affects the way the body processes glucose [blood sugar]); Vascular Dementia (a brain condition that affects thinking, memory, and behavior, and is caused by damaged blood vessels in the brain); Pressure Ulcer of Sacral Region (made up of the sacrum, a triangular bone at the base of the spine, and the coccyx [tailbone]), Stage 3; Anxiety and MDD (a mood disorder that causes a persistent feeling of sadness and loss of interest). A BIMS score of 9 suggested Resident #1 had a moderate cognitive decline. Resident #1 required maximal assistance from staff for ADLs. Resident #1 was always incontinent of bowel and bladder. The Quarterly MDS reflected Resident #1 had a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries, and had one or more unhealed pressure ulcers/injuries. Resident #1 was transferred to the hospital on 09/15/24 for a non-wound related issue. A record review of Resident #1's comprehensive care plan, last care plan review completed 07/12/24 reflected: [Resident #1] has Diabetes Mellitus and is at risk for complications. (Initiated: 06/27/23). Interventions included Check all of body for breaks in skin and treat promptly as ordered by doctor; Monitor/document/report to MD PRN for s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation; and Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. [Resident #1] has a potential for pressure ulcer development/alteration in skin integrity r/t impaired mobility requiring assist, obesity, incontinence, DM. Resident has wounds to coccyx [tailbone] and left heel. (Initiated: 06/27/23). Interventions included Assess/record/monitor wound healing at least weekly; Follow facility policies/protocols for the prevention/treatment of skin breakdown; and Notify nurse immediately of any new areas of skin breakdown; . needs assistance to turn/reposition. A record review of Resident #1's Order Summary Report printed 09/21/24 reflected: Order date 08/28/24: Clean left heel with NS, pat dry, paint with betadine and leave open to air r/t DTI (a type of pressure ulcer that occurs when soft tissue is damaged by prolonged pressure or shear forces) daily and PRN. Order date 09/03/24: Cleanse stage 3 pressure wound to coccyx with NS, pat dry, apply calcium silver alginate, and cover with gauze island with border. One time a day for stage 3 pressure wound to coccyx for 30 days. [Discontinued 09/10/24] Order date 09/10/24: cleanse unstageable (due to necrosis) to the coccyx with 1/4% Dakin's Solution, gently pack wound using 1/4% Dakin's wet to moist Keflex gauze, apply ABD pad, and cover with border gauze island dressing daily and PRN soilage/dislodgement. One time a day for Unstageable pressure wound to coccyx for 30 days. Record review of Resident #1's September 2024 TAR revealed the orders were implemented as written. Record review of Resident #1's WMD visit notes reflected: Date: 08/20/24. Resident #1 was seen for wounds on left heel; coccyx. Stage 3 pressure wound, coccyx - Resolved on 08/20/24. Date: 09/03/24. Resident #1 was seen for wounds on left heel; coccyx. Stage 3 pressure wound, coccyx. Duration greater than 1 day. Objective healing/maintain healing. Wound size: 5 cm x 1.5 cm x 0.1 cm. Exudate: Moderate Serous. 100% granulation tissue. Dressing Treatment Plan: Apply Alginate calcium with silver. Cover with gauze island with border dressing. Apply zinc ointment to peri wound. Once daily. Recommendations: Off-load wound; Reposition per facility protocol. Date: 09/10/24. Resident #1 was seen for wounds on coccyx; left heel. Unstageable (due to necrosis) pressure wound, coccyx. Duration greater than 8 days. Objective healing/maintain healing. Wound size: 12 cm x 10 cm x 0.1 cm. Odor. Exudate: Moderate Serosanguinous. Thick adherent devitalized necrotic tissue (70%), Sough (10%), Granulation tissue (20%). Wound progress: Exacerbated. Dressing Treatment Plan: Apply sodium hypochlorite solution (Dakin's). Use 1/4% Dakin's solution wet to moist Keflex gauze to loosely pack wound. Cover with ABD pad. Apply zinc ointment to peri wound. Once daily. Recommendations: Off-load wound; Reposition per facility protocol. RESIDENT #6 A record review of Resident #6's Quarterly MDS Assessment, dated 8/19/24, revealed a [AGE] year-old male who admitted on [DATE]. Resident #6 had a history and diagnoses of T2DM (a chronic condition that affects the way the body processes glucose [blood sugar]); Muscle wasting and Atrophy; and Pressure Ulcer of Sacral Region, Stage 4. A BIMS score of 12 suggested Resident #6 had a moderate cognitive decline. Resident #6 had a suprapubic indwelling urinary catheter ([SPC] placed 07/19/24) and was frequently incontinent of bowel. A record review of Resident #6's comprehensive care plan, initiated 03/30/23, next review date 11/06/24, reflected: [Resident #6] has an actual pressure ulcer and the potential for pressure ulcer development/alteration in skin integrity r/t impaired mobility, cognitive impairment, Diabetes, nutritional deficits, and occasional bowel incontinence. Stage 4 pressure ulcer to sacral area. Interventions included Administer protein supplements as ordered; Administer treatments as ordered and monitor for effectiveness; Administer Vitamin C as ordered; Assess/record/monitor wound healing at least weekly; Follow facility protocols for the prevention/treatment of skin breakdown; and requires the use of an air mattress. A record review of Resident #6's Order Summary Report printed 09/21/24 reflected: Order date 08/08/24: Ensure LAL mattress is on and inflated every shift for wound care. Record review of Resident #6's September 2024 TAR revealed the orders were implemented as written with nurse responses of on, yes, or ok. During an observation and interview on 09/22/24 at 1:57 PM, Resident #6 was in a semi-side-lying (left lateral and back) position on a LAL mattress with a digital pump placed at the foot of the bed. The pump's power button was dim and in the ON position, the weight setting in lbs knob pointed towards 150 (lbs.), there was no sound, and the mattress did not appear to be inflated. The pump's plug was noted on the floor, under the bed, not inserted into a power outlet. Resident #6 had a SPC in place at the lower midline abdominal area below the belly button and above the pubic bone. A 4 x 4 split gauze was secured over the SPC insert site. There was no indwelling urinary catheter strap in place to prevent pulling or tugging. The SPC tubing laid across Resident #6's right leg connected to a closed system drainage bag that hung on the bed rail. Resident #6 was pleasant and willingly participated in an interview. Resident #6 was alert and oriented to person, place, time of day, and situation. Resident #6 said his bed was not on, it has been off. Resident #6 could not say how long the mattress was not inflated. Resident #6 denied current pain related to the non-functioning mattress. RESIDENT #7 A record review of Resident #7's Quarterly MDS Assessment, dated 06/18/24, revealed a [AGE] year-old female who admitted on [DATE]. Resident #7 had a history and diagnoses of Arthritis; Alzheimer's Disease; Malnutrition; Anxiety Disorder; and Depression. A BIMS score of 9 suggested Resident #7 had a moderate cognitive decline. Resident #7 was always incontinent of bowel and bladder. Resident #7 MDS assessment reflected a risk of developing pressure ulcers/injuries. A pressure reducing device for bed reflected as skin and ulcer/injury treatments in place. A record review of Resident #7's comprehensive care plan, last reviewed 06/12/24, reflected: [Resident #7] has a potential for pressure ulcer development. Resident has abscess to left chest (Initiated: 05/29/24; Revision: 09/17/24). Interventions included Administer treatments as ordered and monitor for effectiveness (Initiated: 09/18/24); assess/record/monitor wound healing at least weekly (Initiated: 09/18/24); Follow facility policies/protocols for the prevention/treatment of skin breakdown; and Resident has a low air loss mattress (Initiated: 08/16/24). A record review of Resident #7's Order Summary Report printed 09/21/24, reflected in part: Start date 09/04/24: Cleanse wound to coccyx with NS, pat dry, apply zinc ointment daily and PRN soilage/dislodgement two times a day for wound to coccyx for 30 days. [discontinued 09/17/24] A record review of Resident #7's Order Summary Report printed 09/22/24, reflected in part: Start date 09/22/24: Low air loss mattress. Nurse to check for proper functioning and settings every shift to promote wound healing. Record review of Resident #7's weight summary revealed last weight on 09/09/24 at 4:26 PM was 98.1 pounds. During an observation on 09/21/24 at 3:40 PM, Resident #7 laid on her back on a LAL mattress with a digital pump placed at the foot of the bed. The pump's power button was in the ON position and the weight setting in lbs knob pointed towards 280 (lbs.). During an interview on 09/21/24 at 2:37 PM, the WCN said that Resident #1 was seen by the WMD for a Stage 3 coccyx wound on 09/03/24 that was resolved on 08/20/24. The WCN said that the wound had visibly increased and was documented by the WMD 09/10/24. The WCN said that she tried to monitor Resident #1 throughout the day during the week, because Resident #1 could not reposition herself and wanted to make sure Resident #1 needed to keep the coccyx wound offloaded. The WCN said she did not work on 09/11/24 or 09/12/24. The WCN said when she returned on 09/13/24 the wound length had increased, there was some slough over the wound, and a slight odor. The WCN said that Resident #1 was discharged from the facility when she returned to work on Monday, 09/16/24. During an interview on 09/21/24 at 3:55 PM, LVN B said that she made sure the LAL digital pumps worked by making sure the pump was turned on. LVN B said that she felt the mattress to make sure it was inflated. LVN B could not verbalize what the appropriate settings should be on Resident #7's pump. LVN B said that the maintenance workers determined the settings when the bed was delivered to the room. During an interview on 09/22/24 at 3:06 PM, RN C said that she was the weekend supervisor. RN C said that she only worked at the facility every other weekend. RN C said that her responsibility was to oversee that nurses and CNAs provided care and services to residents to prevent skin breakdown and promote wound healing by providing incontinent care, turning, and repositioning, every two hours and as needed. RN C said that she performed wound care on the weekends unless she had to fill in for a nurse or medication aide that called in or did not show up for work. RN C said that she performed wound care for Resident #1 on Sunday, 09/08/24. RN C said that she did not recall a sign of infection. RN C said that she performed treatment as the order was written, did not measure the wound, or compared past documentation for changes. RN C said that she did not perform wound care on Saturday, 09/07/24 because she filled in for a medication aide who called off. RN C said the nurse was responsible for their assigned residents wound care. During an interview on 09/22/24 at 3:15 PM, LVN B said that she did not know that Resident #6's LAL mattress pump was not plugged in. LVN B pushed the power button to ON to OFF and back to the ON position. LVN B turned the weight setting knob between numbers. LVN B said she did not know what was wrong. Resident #6 spoke up and said, it does not work. LVN B followed the pumps plug when prompted and saw that the plug was not connected to the electrical outlet. LVN B said, I guess when the CNAs pulled the bed away from the wall to assist the resident, they probably pulled the plug out of the wall. LVN B did not plug the pump into the wall during the surveyor's presence. LVN B said that she learned the weight setting was the resident's current weight. During an interview on 09/22/24 at 4:00 PM, the DON said that she expected nurses to follow facility protocols for pressure ulcer prevention and skin management. The DON said that nurses should know the appropriate settings for a resident's LAL mattress digital pump. The DON said that the LAL mattress assisted with off-loading pressure to the resident to prevent wounds and avoid pre-existing wounds from worsening. The DON said that an in-service was initiated with all nursing staff on LAL mattress digital pump settings. Record review of the facility's Skin Integrity Management policy, revised 10/05/16, reflected: Reposition residents at risk for pressure sore or with pressure sores at least every two (2) hours, if unable to turn themselves. Use pillows or foam wedges to keep bony prominences from direct contact . The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two (2) hours in order to prevent pulmonary and renal complications as well as pressure sores . If eschar or necrotic tissue is present, debridement may be indicated. Physicians do surgical debridement only. Record review of the facility's Physician's Orders undated policy reflected: Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 17 residents (Residents #2, #3, #4, and #5) reviewed for infection control. 1. The facility failed to ensure LVN A, MA, and Activity Director monitored residents to ensure they were not exposed to infections during lunch service when Resident #2 was serving lemonade and coffee to residents without proper hand sanitation. 2. The facility failed to ensure Resident #5 did not move around the dining room as he asked other residents for their dinner rolls. This failure placed residents at an increased risk of exposure to infections to include COVID- 19, decreased quality of life, or hospitalization s. Finding included: Review of Resident #2's face sheet dated 9/17/24 reflected he was admitted on [DATE] with diagnoses of Cerebral Infraction due to Embolism (type of stroke that occurs when a blood clot or other blockage travels to the brain and blocks blood flow), Vascular Dementia (brain damage caused by multiple strokes), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), and Aphasia (language disorder that affects a person's ability to communicate). A record review of Resident #2's Quarterly MDS Assessment, dated 06/23/24, reflected a [AGE] year-old male who admitted on [DATE]. Resident #2 had a history and active diagnoses of stroke, Diabetes Mellitus, Hyperlipidemia, Seizure Disorder, and a BIMS score of 11 suggested Resident #2 had a moderate cognitive impaired. A review of Resident #2's Care Plan dated 09/17/24 did not reflect Resident #2 assisting in the dining room during meals. Review of Resident #3's face sheet dated 9/17/24 reflected he was admitted on [DATE] with diagnoses of Anoxic Brain Damage (occurs when the brain is deprived of oxygen), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining), Hypertension (a condition in which the force of the blood against the artery walls is too high). A record review of Resident #3's Quarterly MDS Assessment, dated 06/27/24, reflected a [AGE] year-old male admitted on [DATE]. Resident #3 had a history and active diagnosis of Traumatic Brain Dysfunction, Hypertension, Diabetes Mellitus, and a BIMS score of 13 suggested Resident #2 was cognitively intact. Review of Resident #4's face sheet dated 9/17/24 reflected she was initially admitted [DATE] and readmitted [DATE] with diagnoses of End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Chronic Kidney Disease (a condition that occurs when the kidneys are damaged and cannot filter blood properly), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Dysphasia (a condition that affects your ability to produce and understand spoken language), and Bacteremia (the presence of bacteria in the blood). A record review of Resident #4's Quarterly MDS Assessment, dated 08/24/24, reflected a [AGE] year-old female who admitted on [DATE] and readmitted [DATE]. Resident #4 had a history and active diagnoses of Anemia, Hypertension, Renal insufficiency, Diabetes Mellitus, Hyperlipidemia, Cerebrovascular Accident, Hemiplegia, and a BIMS score of 13 suggested cognitively intact. Review of Resident #5's face sheet dated 9/17/24 reflected he was admitted [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills and eventually the ability to perform daily tasks), Metabolic Encephalopathy (a brain dysfunction caused by a chemical imbalance in the flood that affects the brain), Chronic Kidney Disease (a condition that occurs when the kidneys are damaged and cannot filter blood properly), and Dysphagia (a condition that makes it difficult to move food from the mouth to the esophagus during swallowing). A record review of Resident #5's Quarterly MDS Assessment, dated 06/20/24, reflected an [AGE] year-old female who admitted on [DATE]. Resident #5 had a history and active diagnoses of Non-Traumatic Brain disfunction, Anemia, Hypertension, Renal insufficiency, Alzheimer's Disease, Cerebrovascular Accident, Malnutrition, Anxiety Disorder, Depression, and a BIMS score of 13 suggested cognitively intact. Observation on 09/17/24 at 12:06 PM revealed the Activity Director, LVN-A, and MA were in the dining room assisting residents with meals. At 12:10 Resident #3 raised his glass while looking at Resident #2, Resident #2 went to the table where Resident #3 was sitting and took the glass from him. Resident #2 then went to the ice chest in the dining room and opened the chest, picked up the ice scoop located inside the ice chest and filled the glass with ice, then he put lemonade in the glass and returned the glass to Resident #3. The Activity Director was observed talking to Resident #2 who then left the dining room. Observation on 09/17/24 at 12:25 PM revealed Resident #2 returned to the dining room, Resident #4 called Resident #2 to the table and handed him her coffee cup. Resident #2 took the coffee cup and proceeded to the coffee pot and poured coffee in the cup and handed the cup back to Resident #4. The Activity Director walked over and talked to Resident #2, and he left the dining room. Observation on 09/17/24 at 12:33 PM revealed Resident #5 was rolling around the dining room to all the tables asking other residents if they wanted their dinner roll and received the rolls from other residents. The LVN did not discourage the resident from receiving the rolls from the other residents. Interview on 09/17/24 at 1:34 PM with the MA revealed LVN-A was responsible for monitoring the residents when they were eating in the dining room. She stated Resident #2 had been asked several times not to hang around in the dining room if he was not eating. She stated Resident #2 did not eat in the dining room, he ate in his room. She stated she had received training on infection control, and she learned the best way to prevent the spread of infection or disease was to wash hands or use hand sanitizer. She stated when Resident #2 passed out drinks to the other residents, they were at risk of receiving drinks that were not on their diet. She stated the residents could have received a regular drink instead of a drink intended for them which could spread infection. Interview on 09/17/24 at 1:44 PM with LVN-A revealed he was responsible for monitoring the residents when they ate in the dining room. He stated Resident #2 was independent and he should not serve other residents drinks in the dining room. He stated Resident #2 had been talked to about getting things for the other residents. He stated he did not know if it had been addressed in Resident #2's Care Plan . He stated when the staff spoke to Resident #2 about getting the drinks, Resident #2 would become confrontational. He stated he had continued to deter Resident #2 from touching the ice and drinks. He stated he had received training on infection control and learned the best way to prevent the spread of infection or disease was to wash hands or use hand sanitizer. He stated the residents had been at risk of infection or disease. Interview on 09/17/24 at 1:52 PM with the Activity Director revealed she learned from a family member of Resident #2 that he had previously worked in a diner or kitchen before he came to live at the facility. She stated Resident #2 had been told he was not supposed to get in the ice. She stated the last time he was told not to get in the ice, he yelled at the person who talked to him. She stated the other residents asked Resident #2 for help all the time. She stated he stood in the dining room to watch if the residents spilled something on the floor and he will get a napkin and pick up what was spilled. She stated if she was busy helping other residents, then Resident #2 would get drinks for the other residents. She stated she did not know if the dining issue of getting drinks for other residents had been discussed on Resident #2's Care Plan. She stated she had been trained on infection control. She stated she learned the best way to prevent the spread of infection or disease was to wash hands and use hand sanitizer. She stated the residents were at risk of contamination when served by Resident #2 who had not been properly trained to serve the residents. Interview on 09/17/24 at 2:05 PM with the Administrator revealed she was not aware Resident #2 had been assisting residents while in the dining room. She stated she had not seen him pass drinks when she was in the dining room. She stated this issue had not been addressed on Resident #2's care plan since she became the administrator of the facility in December of 2023. She stated she was sure the staff tried to discourage Resident #2 from assisting the other residents. She stated the residents were at risk of infection contamination because Resident #2 was not trained on serving drinks. She stated the staff had been in-serviced/trained on preventing infection and disease by washing their hands and using hand sanitizer. Interview on 09/17/24 at 2:13 PM with Resident #3 revealed Resident #2 did assist him with drinks during meals. He stated Resident #2 had given him drinks in the dining room several times. He stated when Resident #2 was in the dining room, he asked Resident #2 to get his drinks, he did not ask the staff. He stated there were staff in the dining room during meals. He stated the staff had told Resident #2 he should not be handing out drinks, but Resident #2 did not listen to what the staff said to him. He stated he had never been sick as a result of drinks he received from Resident #2. He stated he drank regular drinks he did not need any special type of drink. Interview on 09/17/24 at 2:21 PM with Resident #2 revealed he helped in the dining room to get the residents their drinks. He stated he did not know he was not supposed to help the other residents with their drinks. He stated there was nothing wrong with him assisting the other residents with their drinks. He stated, he was the cleanest person in the building including the nurses. He stated the staff told him not to give drinks, but he gave drinks because he wanted to give drinks. He stated he knew which residents could have regular drinks and those were the only residents he gave drinks. Interview on 09/17/24 at 2:27 PM with Resident #5 revealed he asked the other residents for their rolls when they did not eat them. He stated he liked the rolls. He stated the other residents were not going to eat their rolls. He stated the staff had never told him he could not ask the other residents for their uneaten rolls. He stated when he collected the rolls, he would take them to his room, and he would eat them later. He stated Resident #2 normally went around the dining room and helped other residents with drinks. He stated he never saw the staff tell Resident #2 not to get drinks. He stated he thought Resident #2 was a paid employee. Interview on 09/17/24 at 2:30 PM with Resident #4 revealed Resident #2 helped in the dining room every day. She stated she asked Resident #2 to refill her coffee. She stated she asked Resident #2 most of the time for a refill her drinks instead of the staff. She stated the staff had told Resident #2 he should not get drinks for the other residents, but he got angry and got the drinks anyway. She stated when he got angry, he yelled at the staff, but he would leave the dining room. She stated Resident #2 never got physical with the staff when they told him not to get drinks. Record review of facility Infection Control In-Service Training dated 02/08/24 reflected MA had been trained on proper hand washing technique. Record review of facility Infection Control In-Service Training dated 05/20/24 reflected LVN-A and the Activity Director had been trained on cleaning the medication cart and disinfecting shower chairs. Record review of facility Dietary Services Policy & Procedure Manual, dated 2012, reflected: Nursing Responsibilities at Meal Service Procedure: Nursing Service associates should follow these guidelines regarding meal service: .15. If the facility elects to use volunteers, family members, and other individuals to pass out trays the facility should provide training to those individuals. 16. Individuals providing assistance should also receive hands-on training regarding such topics as various feeding techniques, the proper use of adaptive equipment and in providing/coordinating emergency services should a resident experience a problem while eating. Record review of facility undated Hand Hygiene policy reflected, Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR are also appropriate for cleaning hands and can be used for direct resident care.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one of two residents (Resident #1) reviewed for suicidal ideation. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. The failure placed residents at risk for neglect. Findings included: Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note dated 07/23/24 which reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately 1/4 full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said, I hope everyone is happy. I just drank this. LVN A said the bottle of hand sanitizer still had about a 1/4 left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurses' station the day of the incident, 08/15/24 and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, and the resident held up a small, pocket size bottle of hand sanitizer. The resident stated she had drunk the sanitizer and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurses' station when the incident occurred, and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet for the facility and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. Review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the this subpart The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and situations that may constitute abuse or neglect to any resident in the facility. An Immediate Jeopardy/Immediate Threat was identified on 08/16/24. The Administrator and the Regional RN were notified of the Immediate Jeopardy on 08/16/24 at 3:33 PM. The IJ template was provided to the facility on [DATE] at 3:48 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F600 Abuse and Neglect The facility failed to ensure a resident had the right to be free of neglect when a resident with a documented diagnosis of suicidal ideation reported that she wanted to kill herself and ingested a small amount of hand sanitizer. Interventions: 1. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 2. All resident rooms were inspected by the Administrator, DON, and ADON for hazardous items that are not allowed in resident rooms as of 8/16/24. All pocket hand sanitizers have been removed from resident rooms and common areas. 3. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. This resident is not actively suicidal. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 4. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 5. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 6. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 7. An QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topics below. The Administrator, DON, and ADON will then in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on Abuse and Neglect on 8/16/24. b. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on hazardous items that are not allowed in resident rooms including alcohol-based hand sanitizer on 8/16/24. c. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Observation on 08/17/24 from 10:35 AM to 11:20 AM of the resident rooms where residents resided on hall 100, 300, and 500 and common areas revealed there were no hazardous items observed in the room or within resident reach to include hand sanitizer. Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - The different types of abuse. - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. - What hazardous items not allowed in resident rooms and what to do if they find them. LVN's A, B, C, D and RNs I, J, K were able to explain what to do if a resident was admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of five residents (Resident #1) reviewed for baseline care plans. The facility failed to establish a base line care plan to address Resident #1's diagnosis of suicidal ideation when she admitted to the facility. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. Findings included: Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note, dated 07/23/24 reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report for Resident #1, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately 1/4 full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said I hope everyone is happy I just drank this. LVN A said the bottle of hand sanitizer still had about a 1/4 left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurse's station the day of the incident, 08/15/24, and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, she held up a small, pocket size bottle of hand sanitizer and stated she had drank it and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurse's station when the incident occurred and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. The MDS nurse further stated RNs were responsible for creating the baseline care plans. Interview on 08/16/24 at 12:27 PM with RN K revealed she had initiated Resident #1's care plan based on her initial assessment. RN K said she never saw the suicidal ideation diagnosis on the resident's face sheet. RN K further stated if she would have seen that diagnosis, she would have made nursing management aware so they could have put precautions in place. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. Review of the facility's undated policy titled Base Line Care Plans reflected the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care An Immediate Jeopardy was identified on 08/16/24. The Administrator and the Regional RN were notified of the Immediate Jeopardy on 08/16/24 at 3:33 PM. The IJ template was provided to the facility on [DATE] at 3:48 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F655 Baseline Care Plan The facility failed to develop a baseline care plan for a resident, who admitted with a documented diagnosis of suicidal ideation. Interventions: 8. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 9. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 10. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 11. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 12. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 13. An ADHOC QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 2. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topic below. The Administrator, DON, and ADON will then in-service all staff on the following topic below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. LVN's A, B, C , D and RNs I, J, K were able to explain what to do if a resident is admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one of two residents (Resident #1) reviewed for neglect. The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. The failure placed residents at risk for neglect. Findings included: Review of the facility's Abuse/Neglect policy and procedure, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .The facility will provide and sure the promotion and protection of resident rights. It is each individuals' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, and mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions .7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. .B. Training The faciilty will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. .C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect. .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. .G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note dated 07/23/24 which reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately 1/4 full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said, I hope everyone is happy. I just drank this. LVN A said the bottle of hand sanitizer still had about a 1/4 left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurses' station the day of the incident, 08/15/24 and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, and the resident held up a small, pocket size bottle of hand sanitizer. The resident stated she had drunk the sanitizer and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurses' station when the incident occurred, and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet for the facility and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. After administrative review, an Immediate Jeopardy was identified on 08/29/24. The Administrator was notified of the Immediate Jeopardy on 08/29/24 4:31 PM. The IJ template was provided to the facility on [DATE] at 4:31 PM. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F600 Abuse and Neglect The facility failed to ensure a resident had the right to be free of neglect when a resident with a documented diagnosis of suicidal ideation reported that she wanted to kill herself and ingested a small amount of hand sanitizer. Interventions: 1. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 2. All resident rooms were inspected by the Administrator, DON, and ADON for hazardous items that are not allowed in resident rooms as of 8/16/24. All pocket hand sanitizers have been removed from resident rooms and common areas. 3. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. This resident is not actively suicidal. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 4. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 5. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 6. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 7. An QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topics below. The Administrator, DON, and ADON will then in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on Abuse and Neglect on 8/16/24. b. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on hazardous items that are not allowed in resident rooms including alcohol-based hand sanitizer on 8/16/24. c. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Observation on 08/17/24 from 10:35 AM to 11:20 AM of the resident rooms where residents resided on hall 100, 300, and 500 and common areas revealed there were no hazardous items observed in the room or within resident reach to include hand sanitizer. Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - The different types of abuse. - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. - What hazardous items not allowed in resident rooms and what to do if they find them. LVN's A, B, C, D and RNs I, J, K were able to explain what to do if a resident was admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two (Residents #1 and #2) of six residents reviewed for abuse. The facility failed to prevent Resident #1 and #2 from having unwanted sexual exposure and contact by Resident #3. This failure placed residents at risk of being abused by a fell ow resident. Findings included: Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 06/15/23. Resident #1 had diagnoses including heart failure, dementia and stroke causing difficulty speaking. Review of Resident #1's discharge MDS, dated [DATE], her BIMS score was not calculated due to her medical conditions. Her Functional Status indicated she required limited assistance with all her ADLs. Review of Resident #1's care plan, dated 12/08/22, revealed she had impaired cognitive function related to her dementia and a communication deficit related to difficulty speaking. Review of Resident #2's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included emphysema, dementia, communication deficit, and anxiety. Review of Resident #2's annual MDS, dated [DATE], her BIMS score was calculated to be 3 indicating severe cognitive impairment. Her Functional Status indicated she required limited assistance with most of her ADLs except locomotion which required supervision only. Review of Resident #2's care plan, dated 04/25/23, revealed she had impaired cognitive function and communication deficits related to dementia, and wandering habits related to dementia. Review of Resident #3's Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included gangrene infection to left toes, anemia, morbid obesity, and kidney disease. On 02/04/21, a diagnosis of sexual dysfunction was added. Review of Resident #3's quarterly MDS, dated [DATE] his BIMS score was calculated to be 15 indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs. Review of Resident #3's discharge MDS, dated [DATE], his BIMS score was calculated at 14 indicating he was still cognitively intact. His Behavior did not indicate he exhibited behaviors directed at others. Review of Resident #3's care plan, dated 06/16/23, revealed he exhibited sexually inappropriate behavior by exposing himself to staff or others who enter his room beginning on 03/03/21. Resident #3 preferred to not wear pants, and draped his lap with blankets, towels or pants. Review of Resident #3's physician orders revealed Resident #3 was started on testosterone replacement therapy at 100 mg weekly on 01/14/21, and it was discontinued on 10/07/21. Review of Resident #3's physician note dated 03/25/21 indicated he was aware of resident #3's hypersexual behaviors and had spoken with him about the behaviors. Review of Resident #3's psychiatrist visit notes dated 11/15/21 revealed he had been taken off testosterone because of inappropriate behavior of exposing himself to staff and physician and standing in his doorway with no clothes on. Review of Resident #3's progress notes revealed the Social Worker documented on 10/07/21: This SW spoke to res about maintaining privacy during masturbation. Reminded him that it is his right but that he must maintain privacy and not allow others into his room during these activities. Res verbalized understanding. Interview on 06/22/23 at 10:00 AM Resident #2 had difficulty speaking. When asked by the surveyor about anyone being inappropriate with her, tears began to form and she stated, I can't tell you. The resident would not make eye contact after that. Interview on 06/22/23 at 10:38 AM the family member of Resident #1 stated she was visiting the resident in the lobby of the facility when the resident complained of being cold. The family member went to the resident's room to retrieve a jacket. When she returned to the lobby, Resident #3 was sitting in his wheelchair directly in front of Resident #1 with no clothes on below the waist leaving his genitals exposed to Resident #1. The family member yelled at Resident #3 and someone from an office came out and took him away. The family member stated Resident #1 was upset and stated, I didn't like that. Interview on 06/22/23 at 12:50 PM the ADON stated on 06/16/23 a CNA was looking for Resident #2, who was known to wander the facility in her wheelchair. The CNA found Resident #2 in Resident #3's room, with her hand on Resident #3's penis and it was being held in place by Resident #3. The CNA called for help and the two residents were separated. Resident #3 was placed on 1:1 monitoring. The ADON stated Resident #3 had been just like any other resident when he was first admitted , but then a couple of years into his stay Resident #3 began to watch pornography on his phone and his TV. Resident #3 began to masturbate after he began watching pornography, and he was educated on keeping his door shut and not doing it when staff were present. The ADON stated staff knew to knock on his door before entering to make sure he was decent before entering his room. Within a few months, Resident #3's behaviors began to expand to exposing himself to staff in his room, and making inappropriate statements to staff about sexual activities he would like to try. The ADON stated in the last two months Resident #3 began to make more explicit comments and requests to staff. The ADON stated Resident #3 had to be counseled after every event reported by staff, which happened at least once a week. The ADON stated that as far as she knew, Resident #3 focused on staff and never involved the residents in his behaviors. The ADON stated the only interventions to curb Resident #3's behaviors, that she knew of, were stopping his testosterone therapy, seeing the psychiatrist, and educating him on his behaviors. Interview on 06/22/23 at 2:00 PM the DON stated Resident #3's behaviors had been restricted to staff in his room until the two episodes when he involved Residents #1 and #2. He stated Resident #3 stayed in his room most of the time, keeping to himself and occasionally going out to the patio. When Resident #3 was out of his room he kept his lap covered with a towel, blanket or a pair of pants. The DON stated whenever there was an incident with staff, Resident #3 would be educated about his behaviors. The DON stated after the incident with Resident #1, that occurred around 4:00 PM on 05/25/23 , Resident #3 was taken back to his room and the DON educated him about his behaviors again. After the incident with Resident #2 on 06/16/23, Resident #3 was placed on 1:1 monitoring in his room, the police were called, and Resident #3 was transferred out of the facility to an all-male facility within about 3 hours. Interview on 06/22/23 at 2:10 PM, LVN A stated she was present for the incident on 05/25/23 between Residents #1 and #3. She stated Resident #3 had been educated about being clothed, or having his private area covered, when he left his room. LVN A stated shortly after that the resident was again back in the hallway, naked and yelling for his medications and had to be educated again. LVN A stated the resident rarely came out of his room, he would come out and yell for medications but could be easily redirected back to his room. She stated she had never seen, or heard about, Resident #3 involving other residents in his behavior. Interview on 06/22/23 at 2:40 PM, CNA B stated Resident #3 stayed in his room most of the time, and he did not interact with the other residents when he came out of his room. When he was out of his room he would cover his lap with something, and if he didn't he would be reminded to do so. She stated he had not heard of Resident #3 being inappropriate with other residents, just with staff. CNA B stated Resident #3 would tell them it was just the way he was, and they would have to deal with it. Review of Resident #3's nursing progress note from 05/25/23 at 5:57 PM written by LVN A revealed: I was called by med aide in the middle of hallway on 500 hall and saw resident completely naked, sitting and propelling on his wc and asking for his pain pills. Res. was covered, educated and redirected to his room. Notified supervisor, DON and SW. Interview on 06/22/23 at 4:00 PM, the Administrator stated as far as she was aware Resident #3 had never involved other residents in his behaviors until the two recent incidents. The Administrator stated Resident #3 had not been closely monitored since his behaviors began in 2021, because his behaviors only affected staff. The Administrator stated that failing to monitor or transfer Resident #3 when his behaviors began, led to him involving two resident in his behaviors. Review of the facility's policy Abuse/Neglect revised on 03/29/18, defined sexual abuse as non-consensual contact of any type with a resident. The policy reflected, The facility will provide the resident, families, and staff an environment free from abuse and neglect.

Based on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for one, (Resident #23) of 17 residents reviewed for abuse. Staff failed to immediately report an allegation of abuse involving Resident #23, to the Administrator, when she was found crying, shaking and afraid after a verbal altercation with Family #1 on 01/18/23 and failed to report to the Administrator when Resident #23 reported that Family #1 had previously grabbed her face and shook it. The failure to report to the Administrator resulted in a lack of investigation and interventions to prevent further abuse. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. The failure placed residents at risk of possible on-going abuse. Findings included: Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations . Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with the APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call, the exact date she could not recall, from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true. The BOM stated she knew protocol was to report any concerns of abuse to the Admin. The BOM stated moving forward she would report all information she receives about abuse to the Admin whether she believed it or not. Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1] and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure, 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to, and she said half-sister but she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said. LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated, days prior to that incident (unable to recall which day), Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know. CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving, and Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM, and she then read the progress notes for Resident #23 for the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of an in-service dated 11/30/22 revealed the BOM, LVN A and CNA B had been in-serviced on Abuse, Neglect, and Exploitation. Review of the facility's Abuse/Neglect policy revised on 03/2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility .C. Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23, exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her [Family #1] had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with family putting their hand on the resident's cheek and verbal altercation involving resident's family that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring of the facility's implementation of the Plan of Removal revealed: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observations, interviews and record reviews the facility failed to implement written policies and procedures that prohibited and prevented abuse for one (Resident #23) of 17 residents reviewed for abuse and neglect. The facility failed to immediately intervene when Resident #23 was overheard by staff to be in a verbal altercation with Family #1 on 01/08/23. The resident was found crying, shaking and visibly afraid. Staff failed to report when Resident #23 let them know through gestures that Family #1 had put their hands on her face and shook it, on an unknown date prior to the 01/08/23 incident. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. The failure placed residents at risk for abuse and neglect. Findings included: Review of the facility's Abuse/Neglect policy revised March 2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility C. Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations. Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with an APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances, and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family. The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call, the exact date she could not recall, from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect, but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true. The BOM stated she knew protocol was to report any concerns of abuse to the Admin. The BOM stated moving forward she would report all information she received about abuse to the Administrator whether she believed it or not. Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1 and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure, 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated, and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to and she said half-sister, and she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money, and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said. LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated days prior to that incident, the exact date she could not recall, Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know. CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving, and Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM and she then read the progress notes for Resident #23 of the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of an in-service dated 11/30/22 revealed the BOM, LVN A and CNA B had been in-serviced on Abuse, Neglect, and Exploitation. An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23 , exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her Family #1 had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with family putting their hand on the resident's cheek and verbal altercation involving resident's family that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring implementation of the Plan of Removal revealed the following: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to provide a safe environment free from abuse for one (Resident #23) of 17 residents reviewed for abuse. Facility staff failed to immediately intervene when Resident #23 and Family #1 were in a verbal altercation on 01/08/23, in the resident's room with the door closed and once staff intervened, Resident #23 was visibly upset and afraid. Days prior to the incident (01/08/23), Resident #23 reported to the BOM, LVN A and CNA B, that Family #1 had grabbed her face and shook it, and the incident was not reported to the Administrator. There were no interventions put in place after the incident to protect the resident and the family continued to visit. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. The failure placed residents at risk for abuse and neglect. Findings included: Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations . Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with the APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call (did not recall the date) from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true . Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1 and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure], 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to and she said half-sister, but she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money, and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said . LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated, days prior to that incident (unable to recall which day), Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know . CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later, LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room, but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving. Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM, and she then read the progress notes for Resident #23 for the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of the facility's Abuse/Neglect policy revised March 2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23 , exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her [Family #1] had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with [Family #1] putting their hand on the resident's cheek and verbal altercation involving resident's daughters that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring of the facility's implementation of the Plan of Removal revealed the following: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure the necessary level of assistance was provided to safely provide incontinent care for Resident #1 resulting a laceration to her forehead which required 8 sutures. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings include: Review of Resident #1's quarterly MDS assessment, dated 05/17/21, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included diabetes, [CONDITION(S)], CVA , [CONDITION(S)], and encounter for attention to gastrostomy. The MDS further reflected the resident had no speech, cognitive skills for daily decision making were severely impaired, and she required total assistance of two staff members for bed mobility, transfers, toilet use and personal hygiene. Review of Resident #1's care plan, revised on 02/02/21, revealed she had an ADL selfcare performance deficit, 2 person asst /hoyer lift (mechanical lift operated by two people used to transfer a person who is unable to bear their own weight) including personal hygiene, bed mobility, and toilet use (the resident required assistance full care with incontinent care). Review of Resident #1's nurses notes dated 06/24/21 documented by the DON, revealed the following, alerted by staff that resident on the floor and asst was needed. Arrived at room to find aide in room, aid removed from room and I called for 911 to be called and for crash cart and supplies. Pressure immediately applied to the front of the head/forehead with clothing that was beside resident. NP and other nurses arrive with NS , gauze, and wrap to hold dressing. Staff assisted with sliding resident towards the end of the bed. Pressure applied and EMT arrived and resumed care, resident taken to the hospital by stretcher . Review of Resident #1's hospital records, dated 06/24/21, and reviewed on 06/25/21, revealed she was diagnosed with a laceration of scalp, initial encounter, fall from height of greater than 3 feet, transient [CONDITION(S)], and hemorrhagic shock. Interview on 06/25/21 at 12:47 PM with the Wound Care Nurse revealed she treated Resident #1's laceration to her forehead and it measured 6 cm X 0.1 cm and had eight sutures after she returned from the hospital. Interview on 06/25/21 at 8:47 AM with the DON revealed CNA A transferred Resident #1 via hoyer lift and the two front hooks came off which caused the resident to fall out and hit her head against the nightstand. CNA A called CNA B by phone, who was next door with another resident, for help, and CNA B went to the nurses station for help. The DON stated she entered Resident #1's and she was on the floor in a pool of blood two feet around her head. She had staff call 911 as she and the Nurse Practitioner tried to located the source of the blood and apply pressure. EMS arrived and Resident #1 was taken to the hospital for evaluation and treatment and was later returned to the facility. The DON further stated the resident was prescribed blood thinners and it appears she had nicked an artery in her head and that was why she had bled so much . The DON stated CNA A was immediately suspended after the incident. Observation on 06/25/21 at 9:11 AM of Resident #1 revealed she was in bed with her eyes closed. There was a bandage to the left side of her forehead and she did not open her eye when she was spoke to. Interview on 06/25/21 at 9:36 PM with CNA B revealed he was across the hall in another resident's room when he got a phone call from CNA A which stated he needed help and he was could hear Resident #1 crying. When CNA B walked in, the resident was on the floor bleeding and he asked CNA A what happened, but CNA A did not respond. CNA B went to the hallway where he alerted the DON and 911 was called. CNA B further stated Resident #1 required two people for transfers by hoyer lift and incontinent care due to her size and the resident was not able to assist when she was rolled over while being changed. Interview on 06/25/21 at 9:57 PM with CNA A revealed he was changing Resident #1 alone , and as he was trying to turn her on her left side, she rolled off the bed on to the floor. Resident #1 was bleeding and he did not want to leave her alone so he called CNA B on the phone. CNA A stated the resident required two people for transfers and incontinent care but admitted he did not ask for assistance at the time because the other staff looked like they were busy. He also said he had never cared for Resident #1 alone, but at the time he just wanted to get things done. CNA A further stated he did not know why he told the DON he was transferring the resident in the hoyer lift, other than he panicked and was scared . Interview on 06/25/21 at 11:52 AM with LVN C revealed the DON had yelled for her and when she entered Resident #1's room, the resident was on the floor and laid face up and there was a lot of blood. She was instructed to get supplies to treat the resident and she was able to see an injury to the resident's forehead. Interview on 06/25/21 at 1:45 PM with the Administrator and the DON revealed they were not aware CNA A had lied to them about the incident with Resident #1 because he had written a statement and signed it stating the resident had fallen out of the hoyer lift when he was transferring her alone. They further stated they thought they had done everything to correct the problem but they would immediately begin the correct in-service to prevent another similar incident. Interview on 06/25/21 at 4:59 PM with the DON revealed all resident that require a two-person assist with transfers and incontinent care should be done with two people, no exceptions, to prevent similar incidents from occurring. Review of a witness statement dated 06/24/21 signed by CNA A reflected the following: CNA B went into room 514 to change the resident in the room using the hoyer lift, the sling came off the bar and the resident fell on the floor, then he called another aide for help on his phone to come help him. The DON arrived and removed me from the room . Review of CNA A's Annual Competency Evaluation, dated 08/03/20 and reviewed on 06/25/21, reflected he had been in-serviced on resident transfers which included using two people when using mechanical lifts and as needed . Review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed dated 2003 reflected the following: Purpose The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for one resident (R#7) of seven residents reviewed for neglect. --Certified Nurse Aide (CNA A) failed to assist Resident #7 to a standing position with a gait belt. --CNA A failed to obain appropriate assistance when completing Resident #7's bathing, dresssing, and transferring, and had the resident hold herself up in a standing position utilizing a grab bar in the shower. As a result, Resident #7 was unable to bear her weight independently and fell , causing a fracture to her tibia that required surgical intervention. These failures could place 24 residents assigned to CNA A and who required one or two staff assistance to stand and transfer at risk for falls and or serious injuries. The findings included: Review of Minimum Data Set (MDS)-Version 3.0 annual assessment with assessment reference date (ARD) of 12/21/17 documented in part that Resident #7 was an [AGE] year old resident to have clear speech with distinct intelligible words. The resident had the ability to express ideas and wants. The resident had the ability to understand others with clear comprehension. The resident's Brief Interview for Mental Status (BIMS) scored 15 indicating that the resident was cognitively intact. The Brief Interview for Mental Status or BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. Resident's assessment documented no signs or symptoms of [MEDICAL CONDITION]; no behaviors of inattention, disorganized thinking or altered level of consciousness. MDS assessment documented the resident to have no potential indicators of [MEDICAL CONDITION] including no hallucinations or delusions. The resident's functional status documented that the resident required extensive assistance from staff for bed mobility and transfers. The MDS documented that the resident was involved with the transfer activity and staff provided weight-bearing support. The resident was evaluated to have total dependence on staff for transfers in and out of showers. Resident was evaluated to be not steady in balance and only able to stabilize with staff when moving from a seated to standing position. Resident was evaluated to be not steady in balance and only able to stabilize with staff assistance when doing a Surface to Surface transfer (including transfer from chair to wheelchair). The resident was evaluated to require a one person physical assist during ADL (assistance of daily living) regardless of resident's self-performance classification. Active [DIAGNOSES REDACTED]. The MDS documented that the resident was alert and oriented and participated in the assessment. Section V documented that the resident was evaluated to be at risk for falls and care planned to minimize falls. The MDS did not evaluate the resident to trigger Care Area Assessment for any cognitive loss or dementia. The resident's MDS was electronically signed by previous Director of Nursing (DON#1). Review of Resident #7's care plan with a start date of 12/21/17, documented that the resident was at risk for falling and had history of falling related to lumbago, [MEDICAL CONDITIONS] arthritis, muscle spasms, system [MEDICAL CONDITION], history of closed lumber fracture and wheelchair use. Care plan documented the resident had a fall on 12/25/17 while transferring from shower chair to wheelchair. The resident's legs gave out. The care-plan's goal was for the resident to remain free from injury. The care plan also documented for staff to give the resident verbal reminders not to ambulate/transfer without assistance. Review of Care Plan with a start date of 12/21/17 documented that Resident #7 required extensive assistance from 1 to 2 staff during transfers, dressing and personal hygiene. Bathing required extensive/total assistance from 1 to 2 staff members. The care-plan documented for staff to assist the resident with ADLs to the extent that was needed to maintain the resident's well- being, independence and safety. The Care-plan also documented for staff to assist the resident with transfers as needed to maintain the resident's safety. Review of Comprehensive Plan of Care regarding the resident's risk for falls updated on 12/25/17 reflected that Resident #7 had unsteady gait. The care plan documented that on 08/24/16, the resident slid to floor from a bed during a transfer, on 09/22/16, slid off a mattress and fell to floor during a self-transfer on 10/23/16. On 12/25/17, the resident fell during a transfer and was sent to the hospital with injury. Review of hospital documents dated 12/26/17 documented Resident #7 sustained a proximal tibial shaft fracture to the right leg from a fall at the nursing facility on 12/25/17. Hospital surgeon documented that Resident #7 received an operative procedure documented as an intramedullary nail fixation of proximal tibial shaft fracture. (The procedure was used for unstable and displaced tibial shaft fractures. The goals of the surgical treatment were to achieve bone union and to restore length, alignment, and rotation of the fractured tibia.) Review of the facility's internal Incident/Accident Report dated 12/25/17 documented that at 11:30 a.m., Resident #7 sustained a fall in the shower room. LVN B documented that the resident fell during a transfer. The facility record indicated the resident was alert and oriented to person, place and time. LVN B documented resident's leg couldn't hold as she transferred and fell to the shower floor; CNA was present. The resident complained of severe pain to her right knee. LVN B documented that the resident's knee appeared swollen and the resident had difficulty standing up. LVN B documented that the resident's physician and responsible party were notified of the fall. LVN B documented that the resident was transferred to the emergency room for further treatment. LVN B documented that the resident and CNA were instructed to .always ask for help during transfer. The document was signed by DON#1 on 12/26/17. Review of facility Witness Statement dated 12/25/17 documented CNA A was present in the shower room with Resident #7 on 12/25/17. The document showed that Resident #7 was alert and oriented and not confused. Brief summary of the incident documented CNA A assisted the resident in transferring from shower chair to power chair. While transferring the resident, .right leg came from under and fell to the shower floor. Resident's statement revealed that her knee felt weak and gave way. Review of facility's Investigation Follow Up revealed Resident #7 fell in the shower room during a transfer on 12/25/17. The facility documented that the staff member did not ask for assistance during the resident transfer and documented a new staff intervention to assist the resident during all future transfers. The document was signed by DON#1 on 12/26/17. During an interview with the Director of Rehab 03/30/18 at 9:40 AM, he stated Resident #7 at the time of the fall, was not independent of transfer. The CNA would have been a contact transfer, meaning hands on guiding the resident on her trunk, arm, or gait belt. He stated the resident would have conducted a pivot transfer from shower chair to motorized wheel chair. He stated before the resident is transferred the chair should have been very close such that the CNA would do a 90 degree pivot and be able to sit in her chair. He stated when a resident is partial to moderate assistance, the aide should always be in contact with the resident. He stated that they (rehab) teach the aides to be in close proximity so that if they begin to feel the resident slip or fall, they can grab the gait belt or the Resident themselves and give them a boost or they guide the chair that is close by. If the resident falls, staff would be able to guide them to the floor. The aide should be in constant contact. He stated the aides should follow the same plan of care that rehab utilizes. He further stated Resident #7 could transfer independently; however, at times Resident #7 would require more assistance depending on pain or other problems. He stated the aides should always utilize a gait belt during a one or two person transfer. During an interview on 03/29/18 at 9:50 a.m., Family Member (FM#1) indicated Resident #7 had a fall and a serious injury at the facility on 12/25/17. FM#1 said Resident #7 sustained multiple fractures to the resident's right leg which required surgery and extensive post operative treatment. FM#1 said that on 12/25/17, he was notified by the facility regarding Resident #7's fall and transfer to the emergency room (ER) at a local hospital. FM#1 said while in the ER, Resident #7 told him that she had fallen in the shower room at the facility. FM#1 said that Resident #7 was in extreme pain and very upset about the fall and injury. FM#1 said that Resident #7 was especially upset because she told (CNA A) that she needed two people to help her during the transfer because she felt weak and could fall. FM #1 said CNA A ignored Resident #7's request for additional help and did not keep the resident from falling or from injury. FM#1 indicated Resident #7 was alert, oriented, aware of her ambulatory limitations and involved with her plan of care. FM#1 said the resident's fall and fractures could have been avoided if (CNA A) would have listened to her. FM#1 said DON#1 indicated the resident's fall and injury were not reportable to the state because it was witnessed by staff. FM#1 indicated that.the facility's neglect was when CNA A ignored the resident's request for assistance during the transfer, and CNA A allowed the resident to transfer to a standing position without close supervision resulting in a fall and injury. During an interview on 3/30/18 at approximately 2:30 p.m., Assistant Director of Nursing (ADON) indicated she had been an employee of the facility over ten years. The ADON said she received in-services regarding Abuse, Neglect and Exploitation annually and after Resident #7's fall. The ADON indicated DON#1 told her that she had had a conversation with FM#1 after the resident's fall and said FM#1 had alleged that the resident had fallen at the facility on 12/25/17 and sustained multiple fractures to her right leg. The ADON indicated Resident #7 told CNA A to get the chair because she started to feel weak during a transfer in the shower room. The ADON said FM#1 alleged that CNA A did not get the chair fast enough contributing to the resident's fall and leg fracture. The ADON said DON#1 told her that the resident's fall was witnessed by staff and did not meet state requirements as a reportable incident. The ADON indicated DON#1 had conducted an internal facility investigation right after the resident's fall and did not determine a reportable incident. The ADON now acknowledged that FM#1 and Resident #7's allegation of staff neglect and serious resident injury resulting from the fall were reportable incidents to the state agency.The ADON said she was familiar with Resident #7's plan of care prior to her fall on 12/25/17. The ADON said the resident required extensive assistance from staff due to her lower extremity weakness and required gait belt assistance with transfers. The ADON indicated that CNA A should have asked for additional staff assistance if the resident's safety was at risk or if the resident requested additional staff assistance during any transfers. During an interview on 3/29/18 at 10:30 a.m., Resident #7 said she resided at the facility for approximately seven years. Resident #7 was alert and oriented to person, place, time and situation while speaking. Resident #7 said she had received physical therapy prior to her fall on 12/25/17. Resident #7 said she had gained lower extremity strength during physical therapy and was able to stand with staff assistance. Resident #7 said that physical therapy staff assisted her during therapy and able to immediately intervene if she lost balance. Resident #7 said she sometimes required two persons to assist with transfers .depending on how weak my legs were. Resident #7 said staff routinely used a gait belt to assist with transfers during physical therapy. Resident #7 indicated she remembered her fall on 12/25/17 and said, How can I forget that day? I'll always remember. Resident #7 said she requested and was scheduled for a shower on 12/25/17. Resident #7 said CNA A assisted her to transfer from her bed to her electric wheelchair prior to her shower on 12/25/17 during the day shift. Resident #7 said CNA A did not use a gait belt during the transfer. Resident #7 said she used her electric wheel chair to move from her room to the shower room. While in the shower room, Resident #7 said CNA A assisted her from the electric wheelchair to a shower chair without a gait belt. Resident #7 said she was then wheeled into the shower area where she showered. Resident #7 said after she showered, CNA A assisted with drying her and dressed her while she was in the shower area. Resident #7 said CNA A asked her to pull herself up to a standing position using a shower rail mounted to the shower wall so that the CNA could finish drying her and to pull her lower clothing up. Resident #7 said she pulled herself up to the standing position using the shower rail and allowed the CNA to finish drying her and to pull up her lower garments. Resident #7 said the CNA did not attempt to assist her to the standing position. The Resident said her legs got weak after standing in the shower area holding onto the shower rail for several moments and told CNA A that she could no longer stand. Resident #7 said the CNA ignored her request while the CNA moved her shower chair to make room for the electric wheel chair. Resident #7 said she repeated her request for help and told the CNA that she was going to need two people because her legs were about to give out, they're not strong. Resident #7 said that the CNA continued with her task in moving the electric wheelchair closer to her but did not follow her requests for additional and immediate help. Resident #7 said she was not able to hold herself up any longer and fell . Resident #7 said she felt severe pain when she landed on the floor. Resident #7 said the CNA then called staff for assistance. Resident #7 said she was transported to the emergency room where she met with FM#1. Resident #7 said she told FM#1 of the fall, injury, CNA A's lack of care and refusal to get additional help from staff when she requested it in the shower room. During an observation on 03/29/18 at 10:45 a.m., Resident #7 was observed to be in her bed and was in no acute distress. Resident #7's post surgical site to her right lower extremity appeared to be pink, not swollen and showed no signs of infection. During an interview on 03/30/18 at 1:52 p.m., CNA A said she received training regarding the use of gait belt for resident transfers, and in-services for Abuse, Neglect and Exploitation during her initial orientation, annual competency training and after Resident #7's fall. CNA A said she assisted Resident #7 to the shower room on 12/25/17 during the day shift. CNA A said she assisted Resident #7 to transfer from her bed to the resident's electrical wheel chair then followed her to the shower room. CNA A said she assisted Resident #7 transfer from the electric wheel chair to a shower chair in the shower room. CNA said that she did not use a gait belt to assist Resident #7 in the transfers because the resident .could do for herself, she could stand by herself. CNA A indicated Resident #7 had received physical therapy at the facility and the resident's lower extremity strength had increased. CNA A said that when Resident #7 had completed her shower, CNA A said she assisted the resident dry herself and assisted with dressing her. CNA A indicated that she asked the resident to use a shower rail to help her stand so that the CNA could finish drying her and to pick up her lower garments. CNA A said that while Resident #7 was standing and holding on to the shower rail, she moved the resident's shower chair to make room for the resident's electric wheelchair. CNA A said, while she was moving the shower chair the resident said, .you know my legs are not too strong. CNA A said that Resident #7 did not ask for additional staff to assist with the transfer at that time. CNA A said she encouraged the resident to Hold on. You can do it and continued to move the shower chair to make room for the electric wheelchair. CNA A said, She could not keep herself up and fell . CNA A said she was not able to reach the resident in time to prevent the fall nor was she in position to control the fall by guiding the resident to the floor. CNA A said she called facility staff for assistance. CNA A indicated the resident was transported to the hospital for further treatment. CNA A said she was not aware that the resident required extensive assistance from staff during all transfers due to the resident's lower extremity weakness or required one to two person assistance with all transfers prior to the resident's fall. CNA A said, .the charge nurse tells us what kind of care the residents need. I don't go into their charts. CNA A said she received in-services regarding transfers after the resident's fall and said that staff were required to use gait belt or Hoyer lift during all resident transfers. CNA A said she did not provide care for Resident #7 after the incident. CNA A said DON#1 asked her about the resident's fall after the incident but did not counsel or reprimmend her in anyway regarding the incident. Review of staff personnel file showed CNA A to have received training regarding resident transfers and in-services in Abuse, Neglect and Exploitation policy and procedures during her initial orientation period, annually and after Resident #7's fall on 12/25/17. During an interview on 03/30/18 at approximately 5:00 p.m., the Administrator indicated she was the Abuse Coordinator at the facility. The Administrator indicated that all staff were required to follow the facility's Abuse, Neglect, Exploitation policy and procedures. During an interview on 03/30/18 at approximately 5:30 p.m., current DON (DON#2) said she was relatively new to the facility. DON#2 said all staff were required to follow the facility's Abuse, Neglect, Exploitation (ANE) policy and procedures. DON#2 indicated all staff were in-serviced annually and as needed in Resident Transfers and ANE policy and procedures. DON#2 acknowledged that all allegations of Abuse, Neglect and Exploitation have to be investigated by the facility and reported to the State Agency. DON#2 indicated the facility's Administrator was the Abuse Coordinator. DON#2 stated she was not the facility's DON during Resident #7's fall and injury on 12/25/17. Review of Nursing Policy and Procedure Gait Belt-Correct Use of last revised (MONTH) 2012, documented that staff were required to always use the gait belt when the resident required hands on assistance to ambulate or transfer. The policy documented required that any resident with an abdominal wound or ostomy will have approval from the charge nurse before gait belt use. The policy also required for staff to know the resident's physical, mental, mobility, strength, balance, motivation, equipment and limitations. The policy required staff to instruct and explain to the resident the gait belt procedure. To give short/concise directions, enlist the resident's help; properly place wheelchair, chair, etc. at angle close to shower chair or bed to prevent slippage during transfer. To Assist a resident to a standing position, grasp gait belt with both hands; one at each side of resident's waist. Brace resident's knees with your knees as necessary-brace feet a same time. Instruct and Assist Resident to stand up. Firmly guide resident as necessary-let resident stand a few moments to gain standing balance. If Resident begins to fall, push against knees with your knees and control fall with belt. To control a fall-pull resident toward you with belt; ease resident to floor by allowing them to slide down your leg. Review of the facility's Abuse - Reportable Events policy revised (MONTH) (YEAR) reflected: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. .Neglect as defined in 42 CFR §483.5 - The failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Serious bodily injury is - 2 Hour Limit: IF the events that cause the reasonable suspicion result in serious bodily injury to a resident, the nursing facility shall report the suspicion immediately, but not later than 2 hours after forming suspicion. This is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation or an injury resulting from criminal sexual abuse. (As defined in CMS SOM Section PP F608). Review of the facility's resident roster dated 03/29/18 documented the census to be 87 residents of which 24 resided in hall 200. Facility staff provided information regarding residents who required assistance with transfers. During the Exit Conference on 03/29/18 at approximately 5:30 p.m., the facility was afforded the opportunity to ask questions about the deficient practice identified during the complaint survey and provide additional information. The Administrator was notified that deficiencies may be added and or deleted after administrative review.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent neglect for one resident (R#7) of seven residents reviewed for neglect. --Certified Nurse Aide (CNA A) failed to assist Resident #7 to a standing position with a gait belt. --CNA A failed to obain appropriate assistance when completing Resident #7's bathing, dresssing, and transferring, and had the resident hold herself up in a standing position utilizing a grab bar in the shower. As a result, Resident #7 was unable to bear her weight independently and fell , causing a fracture to her tibia that required surgical intervention. --The former Director of Nursing (DON#1) failed to report an allegation of neglect regarding Resident #7 on 12/25/17 These failures could place 24 residents assigned to CNA A and who required one or two staff assistance to stand and transfer at risk for falls and or serious injuries. The findings included: Review of the facility's Abuse - Reportable Events policy revised (MONTH) (YEAR) reflected: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. .Neglect as defined in 42 CFR §483.5 - The failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Serious bodily injury is - 2 Hour Limit: IF the events that cause the reasonable suspicion result in serious bodily injury to a resident, the nursing facility shall report the suspicion immediately, but not later than 2 hours after forming suspicion. This is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation or an injury resulting from criminal sexual abuse. (As defined in CMS SOM Section PP F608). Review of Nursing Policy and Procedure Gait Belt-Correct Use of last revised (MONTH) 2012, documented that staff were required to always use the gait belt when the resident required hands on assistance to ambulate or transfer. The policy documented required that any resident with an abdominal wound or ostomy will have approval from the charge nurse before gait belt use. The policy also required for staff to know the resident's physical, mental, mobility, strength, balance, motivation, equipment and limitations. The policy required staff to instruct and explain to the resident the gait belt procedure. To give short/concise directions, enlist the resident's help; properly place wheelchair, chair, etc. at angle close to shower chair or bed to prevent slippage during transfer. To Assist a resident to a standing position, grasp gait belt with both hands; one at each side of resident's waist. Brace resident's knees with your knees as necessary-brace feet a same time. Instruct and Assist Resident to stand up. Firmly guide resident as necessary-let resident stand a few moments to gain standing balance. If Resident begins to fall, push against knees with your knees and control fall with belt. To control a fall-pull resident toward you with belt; ease resident to floor by allowing them to slide down your leg. Review of Minimum Data Set (MDS)-Version 3.0 annual assessment with assessment reference date (ARD) of 12/21/17 documented in part that Resident #7 was an [AGE] year old resident to have clear speech with distinct intelligible words. The resident had the ability to express ideas and wants. The resident had the ability to understand others with clear comprehension. The resident's Brief Interview for Mental Status (BIMS) scored 15 indicating that the resident was cognitively intact. The Brief Interview for Mental Status or BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. Resident's assessment documented no signs or symptoms of [MEDICAL CONDITION]; no behaviors of inattention, disorganized thinking or altered level of consciousness. MDS assessment documented the resident to have no potential indicators of [MEDICAL CONDITION] including no hallucinations or delusions. The resident's functional status documented that the resident required extensive assistance from staff for bed mobility and transfers. The MDS documented that the resident was involved with the transfer activity and staff provided weight-bearing support. The resident was evaluated to have total dependence on staff for transfers in and out of showers. Resident was evaluated to be not steady in balance and only able to stabilize with staff when moving from a seated to standing position. Resident was evaluated to be not steady in balance and only able to stabilize with staff assistance when doing a Surface to Surface transfer (including transfer from chair to wheelchair). The resident was evaluated to require a one person physical assist during ADL (assistance of daily living) regardless of resident's self-performance classification. Active [DIAGNOSES REDACTED]. The MDS documented that the resident was alert and oriented and participated in the assessment. Section V documented that the resident was evaluated to be at risk for falls and care planned to minimize falls. The MDS did not evaluate the resident to trigger Care Area Assessment for any cognitive loss or dementia. The resident's MDS was electronically signed by previous Director of Nursing (DON#1). Review of Resident #7's care plan with a start date of 12/21/17, documented that the resident was at risk for falling and had history of falling related to lumbago, [MEDICAL CONDITIONS] arthritis, muscle spasms, system [MEDICAL CONDITION], history of closed lumber fracture and wheelchair use. Care plan documented the resident had a fall on 12/25/17 while transferring from shower chair to wheelchair. The resident's legs gave out. The care-plan's goal was for the resident to remain free from injury. The care plan also documented for staff to give the resident verbal reminders not to ambulate/transfer without assistance. Review of Care Plan with a start date of 12/21/17 documented that Resident #7 required extensive assistance from 1 to 2 staff during transfers, dressing and personal hygiene. Bathing required extensive/total assistance from 1 to 2 staff members. The care-plan documented for staff to assist the resident with ADLs to the extent that was needed to maintain the resident's well- being, independence and safety. The Care-plan also documented for staff to assist the resident with transfers as needed to maintain the resident's safety. Review of Comprehensive Plan of Care regarding the resident's risk for falls updated on 12/25/17 reflected that Resident #7 had unsteady gait. The care plan documented that on 08/24/16, the resident slid to floor from a bed during a transfer, on 09/22/16, slid off a mattress and fell to floor during a self-transfer on 10/23/16. On 12/25/17, the resident fell during a transfer and was sent to the hospital with injury. Review of hospital documents dated 12/26/17 documented Resident #7 sustained a proximal tibial shaft fracture to the right leg from a fall at the nursing facility on 12/25/17. Hospital surgeon documented that Resident #7 received an operative procedure documented as an intramedullary nail fixation of proximal tibial shaft fracture. (The procedure was used for unstable and displaced tibial shaft fractures. The goals of the surgical treatment were to achieve bone union and to restore length, alignment, and rotation of the fractured tibia.) Review of the facility's internal Incident/Accident Report dated 12/25/17 documented that at 11:30 a.m., Resident #7 sustained a fall in the shower room. LVN B documented that the resident fell during a transfer. The facility record indicated the resident was alert and oriented to person, place and time. LVN B documented resident's leg couldn't hold as she transferred and fell to the shower floor; CNA was present. The resident complained of severe pain to her right knee. LVN B documented that the resident's knee appeared swollen and the resident had difficulty standing up. LVN B documented that the resident's physician and responsible party were notified of the fall. LVN B documented that the resident was transferred to the emergency room for further treatment. LVN B documented that the resident and CNA were instructed to .always ask for help during transfer. The document was signed by DON#1 on 12/26/17. Review of facility Witness Statement dated 12/25/17 documented CNA A was present in the shower room with Resident #7 on 12/25/17. The document showed that Resident #7 was alert and oriented and not confused. Brief summary of the incident documented CNA A assisted the resident in transferring from shower chair to power chair. While transferring the resident, .right leg came from under and fell to the shower floor. Resident's statement revealed that her knee felt weak and gave way. Review of facility's Investigation Follow Up revealed Resident #7 fell in the shower room during a transfer on 12/25/17. The facility documented that the staff member did not ask for assistance during the resident transfer and documented a new staff intervention to assist the resident during all future transfers. The document was signed by DON#1 on 12/26/17. During an interview with the Director of Rehab 03/30/18 at 9:40 AM, he stated Resident #7 at the time of the fall, was not independent of transfer. The CNA would have been a contact transfer, meaning hands on guiding the resident on her trunk, arm, or gait belt. He stated the resident would have conducted a pivot transfer from shower chair to motorized wheel chair. He stated before the resident is transferred the chair should have been very close such that the CNA would do a 90 degree pivot and be able to sit in her chair. He stated when a resident is partial to moderate assistance, the aide should always be in contact with the resident. He stated that they (rehab) teach the aides to be in close proximity so that if they begin to feel the resident slip or fall, they can grab the gait belt or the Resident themselves and give them a boost or they guide the chair that is close by. If the resident falls, staff would be able to guide them to the floor. The aide should be in constant contact. He stated the aides should follow the same plan of care that rehab utilizes. He further stated Resident #7 could transfer independently; however, at times Resident #7 would require more assistance depending on pain or other problems. He stated the aides should always utilize a gait belt during a one or two person transfer. During an interview on 03/29/18 at 9:50 a.m., Family Member (FM#1) indicated Resident #7 had a fall and a serious injury at the facility on 12/25/17. FM#1 said Resident #7 sustained multiple fractures to the resident's right leg which required surgery and extensive post operative treatment. FM#1 said that on 12/25/17, he was notified by the facility regarding Resident #7's fall and transfer to the emergency room (ER) at a local hospital. FM#1 said while in the ER, Resident #7 told him that she had fallen in the shower room at the facility. FM#1 said that Resident #7 was in extreme pain and very upset about the fall and injury. FM#1 said that Resident #7 was especially upset because she told (CNA A) that she needed two people to help her during the transfer because she felt weak and could fall. FM #1 said CNA A ignored Resident #7's request for additional help and did not keep the resident from falling or from injury. FM#1 indicated Resident #7 was alert, oriented, aware of her ambulatory limitations and involved with her plan of care. FM#1 said the resident's fall and fractures could have been avoided if (CNA A) would have listened to her. FM#1 said DON#1 indicated the resident's fall and injury were not reportable to the state because it was witnessed by staff. FM#1 indicated that.the facility's neglect was when CNA A ignored the resident's request for assistance during the transfer, and CNA A allowed the resident to transfer to a standing position without close supervision resulting in a fall and injury. During an interview on 3/30/18 at approximately 2:30 p.m., Assistant Director of Nursing (ADON) indicated she had been an employee of the facility over ten years. The ADON said she received in-services regarding Abuse, Neglect and Exploitation annually and after Resident #7's fall. The ADON indicated DON#1 told her that she had had a conversation with FM#1 after the resident's fall and said FM#1 had alleged that the resident had fallen at the facility on 12/25/17 and sustained multiple fractures to her right leg. The ADON indicated Resident #7 told CNA A to get the chair because she started to feel weak during a transfer in the shower room. The ADON said FM#1 alleged that CNA A did not get the chair fast enough contributing to the resident's fall and leg fracture. The ADON said DON#1 told her that the resident's fall was witnessed by staff and did not meet state requirements as a reportable incident. The ADON indicated DON#1 had conducted an internal facility investigation right after the resident's fall and did not determine a reportable incident. The ADON now acknowledged that FM#1 and Resident #7's allegation of staff neglect and serious resident injury resulting from the fall were reportable incidents to the state agency.The ADON said she was familiar with Resident #7's plan of care prior to her fall on 12/25/17. The ADON said the resident required extensive assistance from staff due to her lower extremity weakness and required gait belt assistance with transfers. The ADON indicated that CNA A should have asked for additional staff assistance if the resident's safety was at risk or if the resident requested additional staff assistance during any transfers. During an interview on 3/29/18 at 10:30 a.m., Resident #7 said she resided at the facility for approximately seven years. Resident #7 was alert and oriented to person, place, time and situation while speaking. Resident #7 said she had received physical therapy prior to her fall on 12/25/17. Resident #7 said she had gained lower extremity strength during physical therapy and was able to stand with staff assistance. Resident #7 said that physical therapy staff assisted her during therapy and able to immediately intervene if she lost balance. Resident #7 said she sometimes required two persons to assist with transfers .depending on how weak my legs were. Resident #7 said staff routinely used a gait belt to assist with transfers during physical therapy. Resident #7 indicated she remembered her fall on 12/25/17 and said, How can I forget that day? I'll always remember. Resident #7 said she requested and was scheduled for a shower on 12/25/17. Resident #7 said CNA A assisted her to transfer from her bed to her electric wheelchair prior to her shower on 12/25/17 during the day shift. Resident #7 said CNA A did not use a gait belt during the transfer. Resident #7 said she used her electric wheel chair to move from her room to the shower room. While in the shower room, Resident #7 said CNA A assisted her from the electric wheelchair to a shower chair without a gait belt. Resident #7 said she was then wheeled into the shower area where she showered. Resident #7 said after she showered, CNA A assisted with drying her and dressed her while she was in the shower area. Resident #7 said CNA A asked her to pull herself up to a standing position using a shower rail mounted to the shower wall so that the CNA could finish drying her and to pull her lower clothing up. Resident #7 said she pulled herself up to the standing position using the shower rail and allowed the CNA to finish drying her and to pull up her lower garments. Resident #7 said the CNA did not attempt to assist her to the standing position. The Resident said her legs got weak after standing in the shower area holding onto the shower rail for several moments and told CNA A that she could no longer stand. Resident #7 said the CNA ignored her request while the CNA moved her shower chair to make room for the electric wheel chair. Resident #7 said she repeated her request for help and told the CNA that she was going to need two people because her legs were about to give out, they're not strong. Resident #7 said that the CNA continued with her task in moving the electric wheelchair closer to her but did not follow her requests for additional and immediate help. Resident #7 said she was not able to hold herself up any longer and fell . Resident #7 said she felt severe pain when she landed on the floor. Resident #7 said the CNA then called staff for assistance. Resident #7 said she was transported to the emergency room where she met with FM#1. Resident #7 said she told FM#1 of the fall, injury, CNA A's lack of care and refusal to get additional help from staff when she requested it in the shower room. During an observation on 03/29/18 at 10:45 a.m., Resident #7 was observed to be in her bed and was in no acute distress. Resident #7's post surgical site to her right lower extremity appeared to be pink, not swollen and showed no signs of infection. During an interview on 03/30/18 at 1:52 p.m., CNA A said she received training regarding the use of gait belt for resident transfers, and in-services for Abuse, Neglect and Exploitation during her initial orientation, annual competency training and after Resident #7's fall. CNA A said she assisted Resident #7 to the shower room on 12/25/17 during the day shift. CNA A said she assisted Resident #7 to transfer from her bed to the resident's electrical wheel chair then followed her to the shower room. CNA A said she assisted Resident #7 transfer from the electric wheel chair to a shower chair in the shower room. CNA said that she did not use a gait belt to assist Resident #7 in the transfers because the resident .could do for herself, she could stand by herself. CNA A indicated Resident #7 had received physical therapy at the facility and the resident's lower extremity strength had increased. CNA A said that when Resident #7 had completed her shower, CNA A said she assisted the resident dry herself and assisted with dressing her. CNA A indicated that she asked the resident to use a shower rail to help her stand so that the CNA could finish drying her and to pick up her lower garments. CNA A said that while Resident #7 was standing and holding on to the shower rail, she moved the resident's shower chair to make room for the resident's electric wheelchair. CNA A said, while she was moving the shower chair the resident said, .you know my legs are not too strong. CNA A said that Resident #7 did not ask for additional staff to assist with the transfer at that time. CNA A said she encouraged the resident to Hold on. You can do it and continued to move the shower chair to make room for the electric wheelchair. CNA A said, She could not keep herself up and fell . CNA A said she was not able to reach the resident in time to prevent the fall nor was she in position to control the fall by guiding the resident to the floor. CNA A said she called facility staff for assistance. CNA A indicated the resident was transported to the hospital for further treatment. CNA A said she was not aware that the resident required extensive assistance from staff during all transfers due to the resident's lower extremity weakness or required one to two person assistance with all transfers prior to the resident's fall. CNA A said, .the charge nurse tells us what kind of care the residents need. I don't go into their charts. CNA A said she received in-services regarding transfers after the resident's fall and said that staff were required to use gait belt or Hoyer lift during all resident transfers. CNA A said she did not provide care for Resident #7 after the incident. CNA A said DON#1 asked her about the resident's fall after the incident but did not counsel or reprimmend her in anyway regarding the incident. Review of staff personnel file showed CNA A to have received training regarding resident transfers and in-services in Abuse, Neglect and Exploitation policy and procedures during her initial orientation period, annually and after Resident #7's fall on 12/25/17. During an interview on 03/30/18 at approximately 5:00 p.m., the Administrator indicated she was the Abuse Coordinator at the facility. The Administrator indicated that all staff were required to follow the facility's Abuse, Neglect, Exploitation policy and procedures. During an interview on 03/30/18 at approximately 5:30 p.m., current DON (DON#2) said she was relatively new to the facility. DON#2 said all staff were required to follow the facility's Abuse, Neglect, Exploitation (ANE) policy and procedures. DON#2 indicated all staff were in-serviced annually and as needed in Resident Transfers and ANE policy and procedures. DON#2 acknowledged that all allegations of Abuse, Neglect and Exploitation have to be investigated by the facility and reported to the State Agency. DON#2 indicated the facility's Administrator was the Abuse Coordinator. DON#2 stated she was not the facility's DON during Resident #7's fall and injury on 12/25/17. Review of the facility's resident roster dated 03/29/18 documented the census to be 87 residents of which 24 resided in hall 200. Facility staff provided information regarding residents who required assistance with transfers. During the Exit Conference on 03/29/18 at approximately 5:30 p.m., the facility was afforded the opportunity to ask questions about the deficient practice identified during the complaint survey and provide additional information. The Administrator was notified that deficiencies may be added and or deleted after administrative review.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistive device to prevent an accident for one resident (R#7) of seven residents reviewed for falls. --Certified Nurse Aide (CNA A) failed to assist Resident #7 to a standing position with a gait belt. --CNA A failed to obain appropriate assistance when completing Resident #7's bathing, dresssing, and transferring, and had the resident hold herself up in a standing position utilizing a grab bar in the shower. As a result, Resident #7 was unable to bear her weight independently and fell , causing a fracture to her tibia that required surgical intervention. These failures could place 24 residents assigned to CNA A and who required one or two staff assistance to stand and transfer at risk for falls and or serious injuries. The findings included: Review of Minimum Data Set (MDS)-Version 3.0 annual assessment with assessment reference date (ARD) of 12/21/17 documented in part that Resident #7 was an [AGE] year old resident to have clear speech with distinct intelligible words. The resident had the ability to express ideas and wants. The resident had the ability to understand others with clear comprehension. The resident's Brief Interview for Mental Status (BIMS) scored 15 indicating that the resident was cognitively intact. The Brief Interview for Mental Status or BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. Resident's assessment documented no signs or symptoms of [MEDICAL CONDITION]; no behaviors of inattention, disorganized thinking or altered level of consciousness. MDS assessment documented the resident to have no potential indicators of [MEDICAL CONDITION] including no hallucinations or delusions. The resident's functional status documented that the resident required extensive assistance from staff for bed mobility and transfers. The MDS documented that the resident was involved with the transfer activity and staff provided weight-bearing support. The resident was evaluated to have total dependence on staff for transfers in and out of showers. Resident was evaluated to be not steady in balance and only able to stabilize with staff when moving from a seated to standing position. Resident was evaluated to be not steady in balance and only able to stabilize with staff assistance when doing a Surface to Surface transfer (including transfer from chair to wheelchair). The resident was evaluated to require a one person physical assist during ADL (assistance of daily living) regardless of resident's self-performance classification. Active [DIAGNOSES REDACTED]. The MDS documented that the resident was alert and oriented and participated in the assessment. Section V documented that the resident was evaluated to be at risk for falls and care planned to minimize falls. The MDS did not evaluate the resident to trigger Care Area Assessment for any cognitive loss or dementia. The resident's MDS was electronically signed by previous Director of Nursing (DON#1). Review of Resident #7's care plan with a start date of 12/21/17, documented that the resident was at risk for falling and had history of falling related to lumbago, [MEDICAL CONDITIONS] arthritis, muscle spasms, system [MEDICAL CONDITION], history of closed lumber fracture and wheelchair use. Care plan documented the resident had a fall on 12/25/17 while transferring from shower chair to wheelchair. The resident's legs gave out. The care-plan's goal was for the resident to remain free from injury. The care plan also documented for staff to give the resident verbal reminders not to ambulate/transfer without assistance. Review of Care Plan with a start date of 12/21/17 documented that Resident #7 required extensive assistance from 1 to 2 staff during transfers, dressing and personal hygiene. Bathing required extensive/total assistance from 1 to 2 staff members. The care-plan documented for staff to assist the resident with ADLs to the extent that was needed to maintain the resident's well- being, independence and safety. The Care-plan also documented for staff to assist the resident with transfers as needed to maintain the resident's safety. Review of Comprehensive Plan of Care regarding the resident's risk for falls updated on 12/25/17 reflected that Resident #7 had unsteady gait. The care plan documented that on 08/24/16, the resident slid to floor from a bed during a transfer, on 09/22/16, slid off a mattress and fell to floor during a self-transfer on 10/23/16. On 12/25/17, the resident fell during a transfer and was sent to the hospital with injury. Review of hospital documents dated 12/26/17 documented Resident #7 sustained a proximal tibial shaft fracture to the right leg from a fall at the nursing facility on 12/25/17. Hospital surgeon documented that Resident #7 received an operative procedure documented as an intramedullary nail fixation of proximal tibial shaft fracture. (The procedure was used for unstable and displaced tibial shaft fractures. The goals of the surgical treatment were to achieve bone union and to restore length, alignment, and rotation of the fractured tibia.) Review of the facility's internal Incident/Accident Report dated 12/25/17 documented that at 11:30 a.m., Resident #7 sustained a fall in the shower room. LVN B documented that the resident fell during a transfer. The facility record indicated the resident was alert and oriented to person, place and time. LVN B documented resident's leg couldn't hold as she transferred and fell to the shower floor; CNA was present. The resident complained of severe pain to her right knee. LVN B documented that the resident's knee appeared swollen and the resident had difficulty standing up. LVN B documented that the resident's physician and responsible party were notified of the fall. LVN B documented that the resident was transferred to the emergency room for further treatment. LVN B documented that the resident and CNA were instructed to .always ask for help during transfer. The document was signed by DON#1 on 12/26/17. Review of facility Witness Statement dated 12/25/17 documented CNA A was present in the shower room with Resident #7 on 12/25/17. The document showed that Resident #7 was alert and oriented and not confused. Brief summary of the incident documented CNA A assisted the resident in transferring from shower chair to power chair. While transferring the resident, .right leg came from under and fell to the shower floor. Resident's statement revealed that her knee felt weak and gave way. Review of facility's Investigation Follow Up revealed Resident #7 fell in the shower room during a transfer on 12/25/17. The facility documented that the staff member did not ask for assistance during the resident transfer and documented a new staff intervention to assist the resident during all future transfers. The document was signed by DON#1 on 12/26/17. During an interview with the Director of Rehab 03/30/18 at 9:40 AM, he stated Resident #7 at the time of the fall, was not independent of transfer. The CNA would have been a contact transfer, meaning hands on guiding the resident on her trunk, arm, or gait belt. He stated the resident would have conducted a pivot transfer from shower chair to motorized wheel chair. He stated before the resident is transferred the chair should have been very close such that the CNA would do a 90 degree pivot and be able to sit in her chair. He stated when a resident is partial to moderate assistance, the aide should always be in contact with the resident. He stated that they (rehab) teach the aides to be in close proximity so that if they begin to feel the resident slip or fall, they can grab the gait belt or the Resident themselves and give them a boost or they guide the chair that is close by. If the resident falls, staff would be able to guide them to the floor. The aide should be in constant contact. He stated the aides should follow the same plan of care that rehab utilizes. He further stated Resident #7 could transfer independently; however, at times Resident #7 would require more assistance depending on pain or other problems. He stated the aides should always utilize a gait belt during a one or two person transfer. During an interview on 03/29/18 at 9:50 a.m., Family Member (FM#1) indicated Resident #7 had a fall and a serious injury at the facility on 12/25/17. FM#1 said Resident #7 sustained multiple fractures to the resident's right leg which required surgery and extensive post operative treatment. FM#1 said that on 12/25/17, he was notified by the facility regarding Resident #7's fall and transfer to the emergency room (ER) at a local hospital. FM#1 said while in the ER, Resident #7 told him that she had fallen in the shower room at the facility. FM#1 said that Resident #7 was in extreme pain and very upset about the fall and injury. FM#1 said that Resident #7 was especially upset because she told (CNA A) that she needed two people to help her during the transfer because she felt weak and could fall. FM #1 said CNA A ignored Resident #7's request for additional help and did not keep the resident from falling or from injury. FM#1 indicated Resident #7 was alert, oriented, aware of her ambulatory limitations and involved with her plan of care. FM#1 said the resident's fall and fractures could have been avoided if (CNA A) would have listened to her. FM#1 said DON#1 indicated the resident's fall and injury were not reportable to the state because it was witnessed by staff. FM#1 indicated that.the facility's neglect was when CNA A ignored the resident's request for assistance during the transfer, and CNA A allowed the resident to transfer to a standing position without close supervision resulting in a fall and injury. During an interview on 3/30/18 at approximately 2:30 p.m., Assistant Director of Nursing (ADON) indicated she had been an employee of the facility over ten years. The ADON said she received in-services regarding Abuse, Neglect and Exploitation annually and after Resident #7's fall. The ADON indicated DON#1 told her that she had had a conversation with FM#1 after the resident's fall and said FM#1 had alleged that the resident had fallen at the facility on 12/25/17 and sustained multiple fractures to her right leg. The ADON indicated Resident #7 told CNA A to get the chair because she started to feel weak during a transfer in the shower room. The ADON said FM#1 alleged that CNA A did not get the chair fast enough contributing to the resident's fall and leg fracture. The ADON said DON#1 told her that the resident's fall was witnessed by staff and did not meet state requirements as a reportable incident. The ADON indicated DON#1 had conducted an internal facility investigation right after the resident's fall and did not determine a reportable incident. The ADON now acknowledged that FM#1 and Resident #7's allegation of staff neglect and serious resident injury resulting from the fall were reportable incidents to the state agency.The ADON said she was familiar with Resident #7's plan of care prior to her fall on 12/25/17. The ADON said the resident required extensive assistance from staff due to her lower extremity weakness and required gait belt assistance with transfers. The ADON indicated that CNA A should have asked for additional staff assistance if the resident's safety was at risk or if the resident requested additional staff assistance during any transfers. During an interview on 3/29/18 at 10:30 a.m., Resident #7 said she resided at the facility for approximately seven years. Resident #7 was alert and oriented to person, place, time and situation while speaking. Resident #7 said she had received physical therapy prior to her fall on 12/25/17. Resident #7 said she had gained lower extremity strength during physical therapy and was able to stand with staff assistance. Resident #7 said that physical therapy staff assisted her during therapy and able to immediately intervene if she lost balance. Resident #7 said she sometimes required two persons to assist with transfers .depending on how weak my legs were. Resident #7 said staff routinely used a gait belt to assist with transfers during physical therapy. Resident #7 indicated she remembered her fall on 12/25/17 and said, How can I forget that day? I'll always remember. Resident #7 said she requested and was scheduled for a shower on 12/25/17. Resident #7 said CNA A assisted her to transfer from her bed to her electric wheelchair prior to her shower on 12/25/17 during the day shift. Resident #7 said CNA A did not use a gait belt during the transfer. Resident #7 said she used her electric wheel chair to move from her room to the shower room. While in the shower room, Resident #7 said CNA A assisted her from the electric wheelchair to a shower chair without a gait belt. Resident #7 said she was then wheeled into the shower area where she showered. Resident #7 said after she showered, CNA A assisted with drying her and dressed her while she was in the shower area. Resident #7 said CNA A asked her to pull herself up to a standing position using a shower rail mounted to the shower wall so that the CNA could finish drying her and to pull her lower clothing up. Resident #7 said she pulled herself up to the standing position using the shower rail and allowed the CNA to finish drying her and to pull up her lower garments. Resident #7 said the CNA did not attempt to assist her to the standing position. The Resident said her legs got weak after standing in the shower area holding onto the shower rail for several moments and told CNA A that she could no longer stand. Resident #7 said the CNA ignored her request while the CNA moved her shower chair to make room for the electric wheel chair. Resident #7 said she repeated her request for help and told the CNA that she was going to need two people because her legs were about to give out, they're not strong. Resident #7 said that the CNA continued with her task in moving the electric wheelchair closer to her but did not follow her requests for additional and immediate help. Resident #7 said she was not able to hold herself up any longer and fell . Resident #7 said she felt severe pain when she landed on the floor. Resident #7 said the CNA then called staff for assistance. Resident #7 said she was transported to the emergency room where she met with FM#1. Resident #7 said she told FM#1 of the fall, injury, CNA A's lack of care and refusal to get additional help from staff when she requested it in the shower room. During an observation on 03/29/18 at 10:45 a.m., Resident #7 was observed to be in her bed and was in no acute distress. Resident #7's post surgical site to her right lower extremity appeared to be pink, not swollen and showed no signs of infection. During an interview on 03/30/18 at 1:52 p.m., CNA A said she received training regarding the use of gait belt for resident transfers, and in-services for Abuse, Neglect and Exploitation during her initial orientation, annual competency training and after Resident #7's fall. CNA A said she assisted Resident #7 to the shower room on 12/25/17 during the day shift. CNA A said she assisted Resident #7 to transfer from her bed to the resident's electrical wheel chair then followed her to the shower room. CNA A said she assisted Resident #7 transfer from the electric wheel chair to a shower chair in the shower room. CNA said that she did not use a gait belt to assist Resident #7 in the transfers because the resident .could do for herself, she could stand by herself. CNA A indicated Resident #7 had received physical therapy at the facility and the resident's lower extremity strength had increased. CNA A said that when Resident #7 had completed her shower, CNA A said she assisted the resident dry herself and assisted with dressing her. CNA A indicated that she asked the resident to use a shower rail to help her stand so that the CNA could finish drying her and to pick up her lower garments. CNA A said that while Resident #7 was standing and holding on to the shower rail, she moved the resident's shower chair to make room for the resident's electric wheelchair. CNA A said, while she was moving the shower chair the resident said, .you know my legs are not too strong. CNA A said that Resident #7 did not ask for additional staff to assist with the transfer at that time. CNA A said she encouraged the resident to Hold on. You can do it and continued to move the shower chair to make room for the electric wheelchair. CNA A said, She could not keep herself up and fell . CNA A said she was not able to reach the resident in time to prevent the fall nor was she in position to control the fall by guiding the resident to the floor. CNA A said she called facility staff for assistance. CNA A indicated the resident was transported to the hospital for further treatment. CNA A said she was not aware that the resident required extensive assistance from staff during all transfers due to the resident's lower extremity weakness or required one to two person assistance with all transfers prior to the resident's fall. CNA A said, .the charge nurse tells us what kind of care the residents need. I don't go into their charts. CNA A said she received in-services regarding transfers after the resident's fall and said that staff were required to use gait belt or Hoyer lift during all resident transfers. CNA A said she did not provide care for Resident #7 after the incident. CNA A said DON#1 asked her about the resident's fall after the incident but did not counsel or reprimmend her in anyway regarding the incident. Review of staff personnel file showed CNA A to have received training regarding resident transfers and in-services in Abuse, Neglect and Exploitation policy and procedures during her initial orientation period, annually and after Resident #7's fall on 12/25/17. During an interview on 03/30/18 at approximately 5:00 p.m., the Administrator indicated she was the Abuse Coordinator at the facility. The Administrator indicated that all staff were required to follow the facility's Abuse, Neglect, Exploitation policy and procedures. During an interview on 03/30/18 at approximately 5:30 p.m., current DON (DON#2) said she was relatively new to the facility. DON#2 said all staff were required to follow the facility's Abuse, Neglect, Exploitation (ANE) policy and procedures. DON#2 indicated all staff were in-serviced annually and as needed in Resident Transfers and ANE policy and procedures. DON#2 acknowledged that all allegations of Abuse, Neglect and Exploitation have to be investigated by the facility and reported to the State Agency. DON#2 indicated the facility's Administrator was the Abuse Coordinator. DON#2 stated she was not the facility's DON during Resident #7's fall and injury on 12/25/17. Review of Nursing Policy and Procedure Gait Belt-Correct Use of last revised (MONTH) 2012, documented that staff were required to always use the gait belt when the resident required hands on assistance to ambulate or transfer. The policy documented required that any resident with an abdominal wound or ostomy will have approval from the charge nurse before gait belt use. The policy also required for staff to know the resident's physical, mental, mobility, strength, balance, motivation, equipment and limitations. The policy required staff to instruct and explain to the resident the gait belt procedure. To give short/concise directions, enlist the resident's help; properly place wheelchair, chair, etc. at angle close to shower chair or bed to prevent slippage during transfer. To Assist a resident to a standing position, grasp gait belt with both hands; one at each side of resident's waist. Brace resident's knees with your knees as necessary-brace feet a same time. Instruct and Assist Resident to stand up. Firmly guide resident as necessary-let resident stand a few moments to gain standing balance. If Resident begins to fall, push against knees with your knees and control fall with belt. To control a fall-pull resident toward you with belt; ease resident to floor by allowing them to slide down your leg. Review of the facility's Abuse - Reportable Events policy revised (MONTH) (YEAR) reflected: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. .Neglect as defined in 42 CFR §483.5 - The failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Serious bodily injury is - 2 Hour Limit: IF the events that cause the reasonable suspicion result in serious bodily injury to a resident, the nursing facility shall report the suspicion immediately, but not later than 2 hours after forming suspicion. This is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation or an injury resulting from criminal sexual abuse. (As defined in CMS SOM Section PP F608). Review of the facility's resident roster dated 03/29/18 documented the census to be 87 residents of which 24 resided in hall 200. Facility staff provided information regarding residents who required assistance with transfers. During the Exit Conference on 03/29/18 at approximately 5:30 p.m., the facility was afforded the opportunity to ask questions about the deficient practice identified during the complaint survey and provide additional information. The Administrator was notified that deficiencies may be added and or deleted after administrative review.

Based on observation, interview and record review; it was determined the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice for 4 of 10 residents reviewed for Quality of Care (Resident #1, Resident #2, Resident #8 and Resident #10). The facility failed to ensure Resident #1 was not attacked by ants on two separate occasions (7/17/17 and 7/18/17). The facility failed to properly evaluate and treat the ant bites/stings. The 600+ ant bites/stings caused Resident #1 to sustain pain, inflammation, itching and permanent scarring. The facility failed to ensure Resident #2 was not attacked by ants on or about 7/19/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #8 was not attacked by ants on or about 7/22/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #10 was not attacked by ants on or about 8/4/17. The ant bites/stings caused pain, itching and inflammation. On 11/3/17 at 2:45 p.m., Substandard Quality of Care was identified in the area of quality of care. The Administrator was notified that the survey would be extended. The facility's failure to ensure each resident received treatment and care in accordance with professional standards of practice could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for delayed treatment, lack of medical treatment, improper medical treatment, causing pain, infection, [MEDICATION NAME], shock and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D While reviewing Resident #1's Medication Administration Record, [REDACTED] Resident #1 was prescribed [MEDICATION NAME]-[MEDICATION NAME] 10/325mg 1 tab by mouth twice daily as needed for pain. No [MEDICATION NAME] was administered 7/17//17 or 7/18/17, per the MAR. Resident #1 was prescribed [MEDICATION NAME][MEDICATION NAME] 25mg every 6 hours as needed for itching. No [MEDICATION NAME][MEDICATION NAME] was administered 7/17/17 or 7/18/17, per the MAR. While reviewing the emergency care medical records from CareNow for Resident #1, it stated: Description: Many small bites all over bilateral legs, arms, back by ants. (Sic). While reviewing the incident report, dated 7/18/17, for Resident #1, it revealed the physician was not notified of the 7/17/17 ant attack on Resident #1 until 7/17/17 at 10:30 a.m. During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. She was uncertain if the incident was reported to administration. WCN C confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. WCN C confirmed in her nursing judgment, Resident #1 should have been seen by a doctor. When asked if Resident #1 should have been transferred immediately for emergency treatment, she stated, we have to contact the doctor to transfer a resident. When asked what occurs when a resident has an emergency like a [MEDICAL CONDITION], stroke, etc., she stated, oh, we just call 911. She did not have an answer why Resident #1 was not transferred immediately. WCN C confirmed the stings were of a higher severity than they initially appeared. She confirmed neither LVN A nor LVN D had notified the physician. WCN C confirmed she had called the doctor on 7/18/17, but by the time he called back (about 10:00 a.m., Resident #1) was already gone with her daughter. She confirmed LVN A did not notify Resident #1's family. During an interview on 11/3/17 at 8:20 a.m., ADM 1, the current Administrator, confirmed if maintenance told the charge nurse that Resident #1's room should remain unoccupied for 24 hours, then Resident #1 should have not been placed back in the room. He confirmed that information should have been passed on in the shift-to-shift report, and stated, that's just basic nursing there. He refused to comment or speculate why Resident #1 was placed back in the room. He stated, If it was me, I would want to make that decision, but I can't comment on who made the decision. I wasn't here. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident(NAME) she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. Record review of Resident #2's clinical record revealed: Resident #2 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has hearing, vison, communication impairment; BIMS-NA; severe impairment; Depression-2; extensive 1 person assist for all ADL's, dressing, hygiene, bathing and transfers; no upper extremity impairment or lower extremity impairment; frequently incontinent of bladder and always continent of bowel; 1 fall with no injury; at risk for falls and pressure sores. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to [MEDICAL CONDITION], falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. Record review of Resident #8's clinical record revealed: Resident #8 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #8's MDS, dated [DATE], it stated: Resident #8 has vision impairment; BIMS-4; Depression-3; limited 1 person assist for all transfers and bed mobility, hygiene and bathing; walker use; no upper or lower extremity impairment; occasionally incontinent of bowel and bladder; at risk for pressure sores. While reviewing the care plan for Resident #8, dated 10/19/17, it states: Altered skin impairment, [MEDICAL CONDITION], chair bound. While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses' station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 11/3/17 at 3:06 p.m., Resident #8 did not recall being attacked by ants. Record review of Resident #10's clinical record revealed: Resident #10 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #10's MDS, dated [DATE], it stated: Resident #10 has vision impairment; BIMS-11; Depression-15; standby 1 person assist for all ADL's, transfers; limited 1 person assist for dressing, hygiene, and bathing; walker use; no lower or upper extremity impairment; occasionally incontinent of bladder; occasional complaints of pain requiring medication; and at risk for pressure sores. While reviewing the care plan for Resident #10, dated 8/16/17, it states: Ant bites to her right lower shin total of 5 areas (resolved 8/16/17), bladder incontinence, depression, anxiety, ADL dependence on at least 1 person, at risk for falls and pressure sores. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, but I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident(NAME)had been attacked on 7/17/17 also. She confirmed she was not notified immediately by the charge nurse. She confirmed administration should have been notified immediately of the ant attacks, she stated, that's a reportable incident. The nurse should have notified someone. I disciplined her because she did not report the incident. She confirmed the physician and family should have also been notified immediately. She denied knowledge that the physician and family had not been notified until several hours later by the day shift. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin.(NAME)ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. While reviewing the Maintenance Notification Log, it stated: 7/17/17: Description of Work: 'ANTS' Resident 203B was covered in 'ants' in her bed and was showered. Resident in 207B has ants in her room as well. While reviewing the facility's undated Admission Packet, it stated: Statement of Resident Rights You have a right to: 1. All care necessary for you to have the highest possible level of health; . While reviewing the facility's policy for Abuse-Reportable Events, dated 7/17, it stated: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law an incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect cause by another person. Definitions Neglect: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. 4. Identification: c. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident, .immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident. -Administrator -Director of Nurses -Assistant Director of nurses -Charge Nurse d. The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call. While reviewing the facility's policy for Incident/Accident Reporting, dated 7/17, it stated: Policy To ensure that any resident who has an accident/incident will have an investigation completed in an attempt to prevent additional occurrences. Procedure- The Charge Nurse will: -The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or there is a complaint of abuse or neglect. -Notify the physician and document the notification in the medical record. -Notify the responsible party via telephone and document the notification. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for 4 of 10 residents reviewed for physical environment (Resident #1, Resident #2, Resident #8 and Resident #10). The facility failed to ensure Resident #1 was not attacked by ants on two separate occasions (7/17/17 and 7/18/17). The 600+ ant bites/stings caused Resident #1 to sustain pain, inflammation, itching and permanent scarring. The facility failed to ensure Resident #2 was not attacked by ants on or about 7/19/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #8 was not attacked by ants on or about 7/22/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #10 was not attacked by ants on or about 8/4/17. The ant bites/stings caused pain, itching and inflammation. On 11/3/17 at 2:45 p.m., Substandard Quality of Care was identified in the area of quality of care. The Administrator was notified that the survey would be extended. The facility's failure to ensure the resident environment remained as free of accident hazards as possible could place 89 residents requiring showers or baths at risk for poor self-esteem and self-worth, pain, itching, infections, allergic reactions, and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room 203), took resident to shower to make sure no ants on her and then took her to room 408 to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room 408 medications and meal given in 408, a.m. care given and resident returned to room 203 will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches Hydrocortisone ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room 507B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. Hydrocortisone cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu Medrol dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of Hydrocortisone cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room 507 bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/1/17 at 3:00 p.m., Resident #1 was removed from the facility once the extent of ant stings Resident #1 had sustained on 7/17/17 and 7/18/17 was discovered. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. WCN C confirmed Resident #1 returned to her room after pesticide was applied. She confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. Record review of Resident #2's clinical record revealed: Resident #2 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has hearing, vison, communication impairment; BIMS-NA; severe impairment; Depression-2; extensive 1 person assist for all ADL's, dressing, hygiene, bathing and transfers; no upper extremity impairment or lower extremity impairment; frequently incontinent of bladder and always continent of bowel; 1 fall with no injury; at risk for falls and pressure sores. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to seizures, falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. Record review of Resident #8's clinical record revealed: Resident #8 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #8's MDS, dated [DATE], it stated: Resident #8 has vision impairment; BIMS-4; Depression-3; limited 1 person assist for all transfers and bed mobility, hygiene and bathing; walker use; no upper or lower extremity impairment; occasionally incontinent of bowel and bladder; at risk for pressure sores. While reviewing the care plan for Resident #8, dated 10/19/17, it states: Altered skin impairment, [DIAGNOSES REDACTED], chair bound. While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses' station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 11/3/17 at 3:06 p.m., Resident #8 did not recall being attacked by ants. Record review of Resident #10's clinical record revealed: Resident #10 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #10's MDS, dated [DATE], it stated: Resident #10 has vision impairment; BIMS-11; Depression-15; standby 1 person assist for all ADL's, transfers; limited 1 person assist for dressing, hygiene, and bathing; walker use; no lower or upper extremity impairment; occasionally incontinent of bladder; occasional complaints of pain requiring medication; and at risk for pressure sores. While reviewing the care plan for Resident #10, dated 8/16/17, it states: Ant bites to her right lower shin total of 5 areas (resolved 8/16/17), bladder incontinence, depression, anxiety, ADL dependence on at least 1 person, at risk for falls and pressure sores. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, but I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/6/17 at 8:58 a.m., ADM 2 confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident #1 had been attacked on 7/17/17 also. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin. Carpenter ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. While reviewing the Maintenance Notification Log, it stated: 7/17/17: Description of Work: 'ANTS' Resident 203B was covered in 'ants' in her bed and was showered. Resident in 207B has ants in her room as well. While reviewing the facility's undated Admission Packet, it stated: Statement of Resident Rights You have a right to: 1. All care necessary for you to have the highest possible level of health; 3. Safe, decent and clean conditions; . While reviewing the facility's policy for Insect and Rodent Control, dated 5/16, it stated: Policy It is the policy of this home to prevent and control insect and rodent infestations Procedure 1. Arrangements are made with a reputable company for regular treatment for [REDACTED]. 5. Any signs of pest infestations are to be reported immediately to the Dietary Service Manager and Administrator who will contact the pest control service for immediate treatment. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to maintain an effective pest control program to ensure the facility is free of pests for 2 of 4 halls (200 Hall and 500 Hall) reviewed for pest control program (Resident #1, Resident #2, Resident #8 and Resident #10). The facility failed to ensure Resident #1 was not attacked by ants in her room on the 200 Hall on 7/17/17. The facility failed to ensure Resident #1 was not attacked by ants on 7/18/17 in her room on the 200 Hall. The ant attack caused Resident #1 to sustain pain, itching, inflammation and permanent scarring. The facility failed to ensure Resident #2 was not attacked by ants in her room on the 200 Hall on or about 7/19/17. The facility failed to ensure Resident #8 was not attacked by ants on the 200 Hall on or about 7/22/17. The facility failed to ensure Resident #10 was not attacked by ants on the 500 Hall on or about 8/4/17. The facility's failure to maintain an effective pest control program to ensure the facility is free of pests could place 89 residents at risk for poor self-esteem and self-worth, pain, itching, infections, allergic reactions, and death. Findings include: During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/1/17 at 3:00 p.m., Resident #1 was removed from the facility once the extent of ant stings Resident #1 had sustained on 7/17/17 and 7/18/17 was discovered. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. WCN C confirmed Resident #1 returned to her room after pesticide was applied. She confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room 203), took resident to shower to make sure no ants on her and then took her to room 408 to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room 408 medications and meal given in 408, a.m. care given and resident returned to room 203 will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room 507B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room 507 bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to [MEDICAL CONDITION], falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator (ADM 2) reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, bit I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 11/6/17 at 8:58 a.m., ADM 2 confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident #1 had been attacked on 7/17/17 also. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin. Carpenter ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. While reviewing the Maintenance Notification Log, it stated: 7/17/17: Description of Work: 'ANTS' Resident 203B was covered in 'ants' in her bed and was showered. Resident in 207B has ants in her room as well. While reviewing the Resident Council Minutes for 6/5/17, it stated: Maintenance: Resident #11-Roaches and spiders in her room (no room number available). Bugs in the 500 hall shower room. Resident #12-Ants in his room (no room number available). While reviewing the Resident Council Minutes for 7/3/17, it stated: Maintenance: Resident #11-Bugs in his room. Resident #13-Tiny bugs in room (500 Hall). Resident #14-Ants and roaches in room (no room number available). Resident #15-Roaches in bathroom (no room number available). While reviewing the Maintenance Notification Log, it stated: 7/17/17: Description of Work: 'ANTS' Resident 203B was covered in 'ants' in her bed and was showered. Resident in 207B has ants in her room as well. While reviewing the facility's undated Admission Packet, it stated: Statement of Resident Rights You have a right to: 1. All care necessary for you to have the highest possible level of health; 3. Safe, decent and clean conditions; . While reviewing the facility's policy for Insect and Rodent Control, dated 5/16, it stated: Policy It is the policy of this home to prevent and control insect and rodent infestations Procedure 1. Arrangements are made with a reputable company for regular treatment for [REDACTED]. 5. Any signs of pest infestations are to be reported immediately to the Dietary Service Manager and Administrator who will contact the pest control service for immediate treatment. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility administrator failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 of 10 residents reviewed for administration (Resident #1, #2, #8, and #10). The Administrator failed to ensure the DON, nursing staff and maintenance staff were providing the necessary care and services to Resident #1 to protect Resident #1 from neglect. Resident #1 was attacked by ants on 7/17/17 at 2:59 a.m., while she lay in bed unable to remove herself from the ant attack. Nursing staff failed to notify the Resident's physician, responsible party and administrator on-call. Resident #1's room was treated with EPA regulated pesticides by maintenance, opposed to a licensed contractor, as required by State regulation. Nursing staff placed Resident #1 back in her room without waiting the required 24 hours as instructed by maintenance. After Resident #1 was placed back in her room, she 1 was attacked by ants on 7/18/17 and sustained over 600 ant bites/stings. Nursing staff failed to properly evaluate and treat Resident #1's ant bites/stings that caused pain, inflammation, itching, after and permanent scarring to her upper and lower legs, back, abdomen and arms. The facility failed to ensure Resident #2 was not attacked by ants on or about 7/19/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #8 was not attacked by ants on or about 7/22/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #10 was not attacked by ants on or about 8/4/17. The ant bites/stings caused pain, itching and inflammation On 11/3/17 at 2:45 p.m., Substandard Quality of Care was identified in the area of neglect. The Administrator was notified that the survey would be extended. The deficient practice of failing to ensure Resident #1 remained out of her room for 24 hours after pesticide application, the failure to properly evaluate and treat Resident #1's 600+ ant bite/stings, and the failure to properly notify the appropriate individuals after the ant attack could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for abuse, neglect, exploitation, delay in treatment, lack of medical treatment, improper medical treatment, causing pain, infection, permanent scarring, [MEDICATION NAME], shock and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE] after her daughter arrived to the facility to find the extent of ant stings Resident #1 had sustained on 7/17/17 and 7/18/17. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D While reviewing Resident #1's Medication Administration Record, [REDACTED] Resident #1 was prescribed [MEDICATION NAME]-[MEDICATION NAME] 10/325mg 1 tab by mouth twice daily as needed for pain. No [MEDICATION NAME] was administered 7/17//17 or 7/18/17, per the MAR. Resident #1 was prescribed [MEDICATION NAME][MEDICATION NAME] 25mg every 6 hours as needed for itching. No [MEDICATION NAME][MEDICATION NAME] was administered 7/17/17 or 7/18/17, per the MAR. While reviewing the emergency care medical records from CareNow for Resident #1, it stated: Description: Many small bites all over bilateral legs, arms, back by ants. (Sic). While reviewing the incident report, dated 7/18/17, for Resident #1, it revealed the physician was not notified of the 7/17/17 ant attack on Resident #1 until 7/17/17 at 10:30 a.m. During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. She was uncertain if the incident was reported to administration. WCN C confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. WCN C confirmed in her nursing judgment, Resident #1 should have been seen by a doctor. When asked if Resident #1 should have been transferred immediately for emergency treatment, she stated, we have to contact the doctor to transfer a resident. When asked what occurs when a resident has an emergency like a [MEDICAL CONDITION], stroke, etc., she stated, oh, we just call 911. She did not have an answer why Resident #1 was not transferred immediately. WCN C confirmed the stings were of a higher severity than they initially appeared. She confirmed neither LVN A nor LVN D had notified the physician. WCN C confirmed she had called the doctor on 7/18/17, but by the time he called back (about 10:00 a.m., Resident #1) was already gone with her daughter. She confirmed LVN A did not notify Resident #1's family. During an interview on 11/3/17 at 8:20 a.m., ADM 1, the current Administrator, confirmed if maintenance told the charge nurse that Resident #1's room should remain unoccupied for 24 hours, then Resident #1 should have not been placed back in the room. He confirmed that information should have been passed on in the shift-to-shift report, and stated, that's just basic nursing there. He refused to comment or speculate why Resident #1 was placed back in the room. He stated, If it was me, I would want to make that decision, but I can't comment on who made the decision. I wasn't here. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident(NAME) she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. Record review of Resident #2's clinical record revealed: Resident #2 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has hearing, vison, communication impairment; BIMS-NA; severe impairment; Depression-2; extensive 1 person assist for all ADL's, dressing, hygiene, bathing and transfers; no upper extremity impairment or lower extremity impairment; frequently incontinent of bladder and always continent of bowel; 1 fall with no injury; at risk for falls and pressure sores. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to [MEDICAL CONDITION], falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. Record review of Resident #8's clinical record revealed: Resident #8 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #8's MDS, dated [DATE], it stated: Resident #8 has vision impairment; BIMS-4; Depression-3; limited 1 person assist for all transfers and bed mobility, hygiene and bathing; walker use; no upper or lower extremity impairment; occasionally incontinent of bowel and bladder; at risk for pressure sores. While reviewing the care plan for Resident #8, dated 10/19/17, it states: Altered skin impairment, [MEDICAL CONDITION], chair bound. While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses' station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 11/3/17 at 3:06 p.m., Resident #8 did not recall being attacked by ants. Record review of Resident #10's clinical record revealed: Resident #10 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #10's MDS, dated [DATE], it stated: Resident #10 has vision impairment; BIMS-11; Depression-15; standby 1 person assist for all ADL's, transfers; limited 1 person assist for dressing, hygiene, and bathing; walker use; no lower or upper extremity impairment; occasionally incontinent of bladder; occasional complaints of pain requiring medication; and at risk for pressure sores. While reviewing the care plan for Resident #10, dated 8/16/17, it states: Ant bites to her right lower shin total of 5 areas (resolved 8/16/17), bladder incontinence, depression, anxiety, ADL dependence on at least 1 person, at risk for falls and pressure sores. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, but I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident(NAME)had been attacked on 7/17/17 also. She confirmed she was not notified immediately by the charge nurse. She confirmed administration should have been notified immediately of the ant attacks, she stated, that's a reportable incident. The nurse should have notified someone. I disciplined her because she did not report the incident. She confirmed the physician and family should have also been notified immediately. She denied knowledge that the physician and family had not been notified until several hours later by the day shift. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin.(NAME)ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. While reviewing the facility's policy for Abuse-Reportable Events, dated 7/17, it stated: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law an incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect cause by another person. Definitions Neglect: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. 4. Identification: c. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident. -Administrator -Director of Nurses -Assistant Director of nurses -Charge Nurse d. The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call. While reviewing the facility's policy for Incident/Accident Reporting, dated 7/17, it stated: Policy To ensure that any resident who has an accident/incident will have an investigation completed in an attempt to prevent additional occurrences. Procedure- The Charge Nurse will: -The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or there is a complaint of abuse or neglect. -Notify the physician and document the notification in the medical record. -Notify the responsible party via telephone and document the notification. While reviewing the facility's undated Admission Packet, it stated: Statement of Resident Rights You have a right to: 1. All care necessary for you to have the highest possible level of health; 3. Safe, decent and clean conditions; . While reviewing the facility's policy for Insect and Rodent Control, dated 5/16, it stated: Policy It is the policy of this home to prevent and control insect and rodent infestations Procedure 1. Arrangements are made with a reputable company for regular treatment for [REDACTED]. 5. Any signs of pest infestations are to be reported immediately to the Dietary Service Manager and Administrator who will contact the pest control service for immediate treatment. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, codes and with acceptable professional standards of practice. The facility failed to ensure the ant infestation was treated by a licensed professional. The ant infestation on Halls 200 and 500 lasted from 7/17/17 until 8/4/17. The ant infestation was treated with an EPA regulated pesticide by the maintenance man. The facility's failure to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, codes and with acceptable professional standards of practice could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for abuse, neglect, exploitation, lack of medical treatment, improper medical treatment, infection, permanent scarring, [MEDICATION NAME], shock and death. Findings include: While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D While reviewing the emergency care medical records from CareNow for Resident #1, it stated: Description: Many small bites all over bilateral legs, arms, back by ants. (Sic). During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. He confirmed he did not have any Defense Dust left or a label for it. During an interview on 11/3/17 at 8:20 a.m., ADM 1, the current administrator, confirmed if maintenance told the charge nurse that Resident #1's room should remain unoccupied for 24 hours, then Resident #1 should have not been placed back in the room. He confirmed that information should have been passed on in the shift-to-shift report, and stated, that's just basic nursing there. He refused to comment or speculate why Resident #1 was placed back in the room. He stated, If it was me, I would want to make that decision, but I can't comment on who made the decision. I wasn't here. During an interview on 11/3/17 at 9:07 a.m., DOA confirmed the maintenance man must have a license to apply the Sterifab and Defense Dust. He confirmed if a product has an EPA registration number, it must be applied by a licensed professional in a nursing facility. During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident #1 had been attacked on 7/17/17 also. She confirmed she had maintenance treated the rooms and called the pest control company. While reviewing the Maintenance Notification Log, it stated: 7/17/17: Description of Work: 'ANTS' Resident 203B was covered in 'ants' in her bed and was showered. Resident in 207B has ants in her room as well. While reviewing the label for Steri-fab, it stated: Bactericide*Sanitizer*Fungicide*Mildewcide*Incesticide*Deodorant*Gemicide*Viricide EPA Reg. Number 397-13 While reviewing the facility's undated Admission Packet, it stated: Statement of Resident Rights You have a right to: 1. All care necessary for you to have the highest possible level of health; 3. Safe, decent and clean conditions; . While reviewing the facility's policy for Insect and Rodent Control, dated 5/16, it stated: Policy It is the policy of this home to prevent and control insect and rodent infestations Procedure 1. Arrangements are made with a reputable company for regular treatment for [REDACTED]. 5. Any signs of pest infestations are to be reported immediately to the Dietary Service Manager and Administrator who will contact the pest control service for immediate treatment. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to implement its written policies and procedures that prohibit and prevent neglect and procedures for reporting incidents of neglect for 4 of 10 residents reviewed for neglect (Resident #1, Resident #2, Resident #8, and Resident #10). The facility failed to protect Resident #1 from ant bites/stings and failed to report an incident where Resident #1 was attacked by ants on two separate occasions (7/17/17 and 7/18/17). Resident #1 was attacked by ants on 7/17/17 at 2:59 a.m. The facility failed to properly evaluate and treat the ant bites/stings that caused pain, inflammation and itching. The Resident's physician was not notified until 10:30 a.m. Administration was not notified of the incident. Resident #1 was attacked again by ants on 7/18/17 at 3:04 a.m. The facility failed to properly evaluate and treat 600+ ant bites/stings that caused pain, inflammation, itching and permanent scarring. The Resident's physician was not notified until 6:57 a.m., and he did not return the phone call until the Resident's daughter removed her from the facility to seek medical treatment. Administration was not notified until morning meeting. The facility failed to protect Resident #2 from ant bites/stings and failed report an incident where Resident #2 was attacked by ants on or about 7/19/17. The facility failed to protect Resident #8 from ant bites/stings and failed report an incident where Resident #8 was attacked by ants on or about 7/22/17. The facility failed to protect Resident #10 from ant bites/stings on or about 8/4/17. The ant bites/stings caused pain, itching and inflammation. The facility's failure to implement its written policies and procedures that prohibit and prevent neglect could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for abuse, neglect, exploitation, delayed treatment, lack of medical treatment, improper medical treatment, causing pain, infection, [MEDICATION NAME], shock and death. Findings include: While reviewing the facility's policy for Abuse-Reportable Events, dated 7/17, it stated: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law an incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect cause by another person. Definitions Neglect: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. 4. Identification: c. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident. -Administrator -Director of Nurses -Assistant Director of nurses -Charge Nurse d. The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call. While reviewing the facility's policy for Incident/Accident Reporting, dated 7/17, it stated: Policy To ensure that any resident who has an accident/incident will have an investigation completed in an attempt to prevent additional occurrences. Procedure- The Charge Nurse will: -The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or there is a complaint of abuse or neglect. -Notify the physician and document the notification in the medical record. -Notify the responsible party via telephone and document the notification. Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D While reviewing Resident #1's Medication Administration Record, [REDACTED] Resident #1 was prescribed [MEDICATION NAME]-[MEDICATION NAME] 10/325mg 1 tab by mouth twice daily as needed for pain. No [MEDICATION NAME] was administered 7/17//17 or 7/18/17, per the MAR. Resident #1 was prescribed [MEDICATION NAME][MEDICATION NAME] 25mg every 6 hours as needed for itching. No [MEDICATION NAME][MEDICATION NAME] was administered 7/17/17 or 7/18/17, per the MAR. While reviewing the emergency care medical records from CareNow for Resident #1, it stated: Description: Many small bites all over bilateral legs, arms, back by ants. (Sic). While reviewing the incident report, dated 7/18/17, for Resident #1, it revealed the physician was not notified of the 7/17/17 ant attack on Resident #1 until 7/17/17 at 10:30 a.m. During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. She was uncertain if the incident was reported to administration. WCN C confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. WCN C confirmed in her nursing judgment, Resident #1 should have been seen by a doctor. When asked if Resident #1 should have been transferred immediately for emergency treatment, she stated, we have to contact the doctor to transfer a resident. When asked what occurs when a resident has an emergency like a [MEDICAL CONDITION], stroke, etc., she stated, oh, we just call 911. She did not have an answer why Resident #1 was not transferred immediately. WCN C confirmed the stings were of a higher severity than they initially appeared. She confirmed neither LVN A nor LVN D had notified the physician. WCN C confirmed she had called the doctor on 7/18/17, but by the time he called back (about 10:00 a.m., Resident #1) was already gone with her daughter. She confirmed LVN A did not notify Resident #1's family. During an interview on 11/3/17 at 8:20 a.m., ADM 1, the current Administrator, confirmed if maintenance told the charge nurse that Resident #1's room should remain unoccupied for 24 hours, then Resident #1 should have not been placed back in the room. He confirmed that information should have been passed on in the shift-to-shift report, and stated, that's just basic nursing there. He refused to comment or speculate why Resident #1 was placed back in the room. He stated, If it was me, I would want to make that decision, but I can't comment on who made the decision. I wasn't here. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident(NAME) she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. Record review of Resident #2's clinical record revealed: Resident #2 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has hearing, vison, communication impairment; BIMS-NA; severe impairment; Depression-2; extensive 1 person assist for all ADL's, dressing, hygiene, bathing and transfers; no upper extremity impairment or lower extremity impairment; frequently incontinent of bladder and always continent of bowel; 1 fall with no injury; at risk for falls and pressure sores. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to [MEDICAL CONDITION], falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. Record review of Resident #8's clinical record revealed: Resident #8 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #8's MDS, dated [DATE], it stated: Resident #8 has vision impairment; BIMS-4; Depression-3; limited 1 person assist for all transfers and bed mobility, hygiene and bathing; walker use; no upper or lower extremity impairment; occasionally incontinent of bowel and bladder; at risk for pressure sores. While reviewing the care plan for Resident #8, dated 10/19/17, it states: Altered skin impairment, [MEDICAL CONDITION], chair bound. While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses' station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 11/3/17 at 3:06 p.m., Resident #8 did not recall being attacked by ants. Record review of Resident #10's clinical record revealed: Resident #10 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #10's MDS, dated [DATE], it stated: Resident #10 has vision impairment; BIMS-11; Depression-15; standby 1 person assist for all ADL's, transfers; limited 1 person assist for dressing, hygiene, and bathing; walker use; no lower or upper extremity impairment; occasionally incontinent of bladder; occasional complaints of pain requiring medication; and at risk for pressure sores. While reviewing the care plan for Resident #10, dated 8/16/17, it states: Ant bites to her right lower shin total of 5 areas (resolved 8/16/17), bladder incontinence, depression, anxiety, ADL dependence on at least 1 person, at risk for falls and pressure sores. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, but I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. During an interview on 11/3/17 at 3:05 p.m., ADM 1, the current administrator, confirmed he was unaware of the issue and stated, I can't speculate, I wasn't employed here. I don't know. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident(NAME)had been attacked on 7/17/17 also. She confirmed she was not notified immediately by the charge nurse. She confirmed administration should have been notified immediately of the ant attacks, she stated, that's a reportable incident. The nurse should have notified someone. I disciplined her because she did not report the incident. She confirmed the physician and family should have also been notified immediately. She denied knowledge that the physician and family had not been notified until several hours later by the day shift. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin.(NAME)ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to ensure residents were free from neglect for 4 of 10 residents reviewed for neglect (Resident #1, Resident #2, Resident #8 and Resident #10). The facility failed to ensure Resident #1 was not attacked by ants on two separate occasions (7/17/17 and 7/18/17). Resident #1 was attacked by ants on 7/17/17 at 2:59 a.m. The facility failed to properly evaluate and treat the ant bites/stings that caused pain, inflammation and itching. The Resident's physician was not notified until 10:30 a.m., and administration was not notified until 7/18/17. The facility failed to ensure Resident #1 remained in a different room after maintenance treated her room with pesticide because she was attacked by ants on 7/17/17. After she was placed back in her room, Resident #1 was attacked by ants on 7/18/17 and sustained over 600 ant bites/stings. The 600+ ant bites/stings caused Resident #1 to sustain pain, inflammation, itching and permanent scarring. The facility failed to ensure Resident #2 was not attacked by ants on or about 7/19/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #8 was not attacked by ants on or about 7/22/17. The ant bites/stings caused pain, itching and inflammation. The facility failed to ensure Resident #10 was not attacked by ants on or about 8/4/17. The ant bites/stings caused pain, itching and inflammation. On 11/3/17 at 2:45 p.m., Substandard Quality of Care was identified in the area of neglect. The Administrator was notified that the survey would be extended. The facility's failure to ensure residents were free from neglect of resident property could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for abuse, neglect, exploitation, lack of medical treatment, improper medical treatment, infection, permanent scarring, [MEDICATION NAME], shock and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 a 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D While reviewing Resident #1's Medication Administration Record, [REDACTED] Resident #1 was prescribed [MEDICATION NAME]-[MEDICATION NAME] 10/325mg 1 tab by mouth twice daily as needed for pain. No [MEDICATION NAME] was administered 7/17//17 or 7/18/17, per the MAR. Resident #1 was prescribed [MEDICATION NAME][MEDICATION NAME] 25mg every 6 hours as needed for itching. No [MEDICATION NAME][MEDICATION NAME] was administered 7/17/17 or 7/18/17, per the MAR. While reviewing the emergency care medical records from CareNow for Resident #1, it stated: Description: Many small bites all over bilateral legs, arms, back by ants. (Sic). While reviewing the incident report, dated 7/18/17, for Resident #1, it revealed the physician was not notified of the 7/17/17 ant attack on Resident #1 until 7/17/17 at 10:30 a.m. During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/2/17 at 10:27 a.m., MAIN confirmed he was notified by an unknown CNA and via the maintenance log that ants had been in a resident's bed during the night on 7/17/17. He confirmed the Resident had already been moved out of the room to another room. MAIN confirmed he treated the room with Sterifab pesticide. He confirmed he informed the charge nurse that day that the Resident should not be returned to the room for 24 hours. He did not remember her name, but he confirmed it was the charge nurse. (The nursing notes and staffing log verified this nurse was LVN B). He stated the Sterifab needs that time to work because it does not kill the ants right away. He stated, it basically gives them the flu, and they bump into each other and take it back to the nest. He confirmed he notified Rentokil of need for pest control services. He confirmed RentoKil informed him it would be 24 hours before they could come treat the resident rooms. He confirmed the following day he was notified that Resident #1 was covered in ants again. He confirmed she should have not be placed back in her room on hall 200. He stated he applied Sterifab around room and Defense Dust in the walls. He confirmed he spoke with the Rentokil serviceman via text, and the ants were identified as carpenter ants. He confirmed carpenter ants are more active at night and tend to swarm when their nest is disturbed. He confirmed she should not have been placed back in her room on hall 200. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. She was uncertain if the incident was reported to administration. WCN C confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. WCN C confirmed in her nursing judgment, Resident #1 should have been seen by a doctor. When asked if Resident #1 should have been transferred immediately for emergency treatment, she stated, we have to contact the doctor to transfer a resident. When asked what occurs when a resident has an emergency like a [MEDICAL CONDITION], stroke, etc., she stated, oh, we just call 911. She did not have an answer why Resident #1 was not transferred immediately. WCN C confirmed the stings were of a higher severity than they initially appeared. She confirmed neither LVN A nor LVN D had notified the physician. WCN C confirmed she had called the doctor on 7/18/17, but by the time he called back (about 10:00 a.m., Resident #1) was already gone with her daughter. She confirmed LVN A did not notify Resident #1's family. During an interview on 11/3/17 at 8:20 a.m., ADM 1, the current Administrator, confirmed if maintenance told the charge nurse that Resident #1's room should remain unoccupied for 24 hours, then Resident #1 should have not been placed back in the room. He confirmed that information should have been passed on in the shift-to-shift report, and stated, that's just basic nursing there. He refused to comment or speculate why Resident #1 was placed back in the room. He stated, If it was me, I would want to make that decision, but I can't comment on who made the decision. I wasn't here. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident(NAME) she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. Record review of Resident #2's clinical record revealed: Resident #2 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has hearing, vison, communication impairment; BIMS-NA; severe impairment; Depression-2; extensive 1 person assist for all ADL's, dressing, hygiene, bathing and transfers; no upper extremity impairment or lower extremity impairment; frequently incontinent of bladder and always continent of bowel; 1 fall with no injury; at risk for falls and pressure sores. While reviewing the care plan for Resident #2, dated 10/9/17, it states: Multiple ant bites to her waist, upper buttocks and hands, impaired cognition, falls, anxiety, bowel and bladder incontinence, ADL assist of 1-2 persons, and at risk for injuries related to [MEDICAL CONDITION], falls, dehydration and pressure sores. While reviewing the nursing notes for Resident #2, it stated: 7/19/17 at 9:50 a.m.: CNA staff reported that Resident has multiple red raised pustule areas. This nurse in Resident's temporary room assessed skin Found 8 red raised pustule areas on lower back and 3 on abdomen area and 1 on right wrist. Vital signs taken BP-148/80, P-76, T-97.5, O2 Sat-98% on room air .Resident had been itching earlier the red raised areas. This nurse notified Resident's sister and notified Doctor. No new orders written . (Sic) - LVN F During an interview on 11/3/17 at 11:35 a.m., LVN F confirmed several Resident rooms had ants. She stated, a couple of residents were affected. About start of summertime ants began coming in rooms. When asked about the Residents affected she stated, (Resident #1), but others were affected because we moved them to my hall. When asked about (Resident #2), she said, I don't know if those were ant bites. They were red, raised areas with pustules on them. Asked if they looked like the injuries sustained by Resident #1, she said, no. I asked how they different, and she responded, well, (Resident #1) had a lot more. She confirmed they did not appear different except the number. Record review of Resident #8's clinical record revealed: Resident #8 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #8's MDS, dated [DATE], it stated: Resident #8 has vision impairment; BIMS-4; Depression-3; limited 1 person assist for all transfers and bed mobility, hygiene and bathing; walker use; no upper or lower extremity impairment; occasionally incontinent of bowel and bladder; at risk for pressure sores. While reviewing the care plan for Resident #8, dated 10/19/17, it states: Altered skin impairment, [MEDICAL CONDITION], chair bound. While reviewing the nursing notes for Resident #8, it stated: 7/22/17 at 7:41 a.m.: Approximately 6:45 a.m. Resident ambulating with walker to nurses' station. Observed right side of face with 2 pustules and red bumps inside of right ear observed, bilateral eyes swollen. Went to room observed dead ants in window and a few alive also Pulled out bed Notices 2 alive ants on floor. Immediately moved Residents to 307 and 310. Weekend Supervisor notified at 6:45 .Doctor notified at 7:10 a.m., DON arrived at 7:00 a.m. Resident family notified of room changed .Maint. notified by DON at 7:17 .M (Sic) LVN B 7/24/17 at 11:54 a.m.: Facility Administrator reported to this nurse that Resident had no ant bites on face. - LVN F During an interview on 11/3/17 at 3:06 p.m., Resident #8 did not recall being attacked by ants. Record review of Resident #10's clinical record revealed: Resident #10 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #10's MDS, dated [DATE], it stated: Resident #10 has vision impairment; BIMS-11; Depression-15; standby 1 person assist for all ADL's, transfers; limited 1 person assist for dressing, hygiene, and bathing; walker use; no lower or upper extremity impairment; occasionally incontinent of bladder; occasional complaints of pain requiring medication; and at risk for pressure sores. While reviewing the care plan for Resident #10, dated 8/16/17, it states: Ant bites to her right lower shin total of 5 areas (resolved 8/16/17), bladder incontinence, depression, anxiety, ADL dependence on at least 1 person, at risk for falls and pressure sores. While reviewing the nursing notes for Resident #10, it stated: 8/4/17 at 11:07 a.m.: Notified by CNA that during resident's shower she noted some insect bites of unknown insect on her right lower leg. 5 bites noted, 3 lateral and 2 medial. Resident reports itching but no pain or stinging at sites. Some scratching marks noted. Resident reported seeing flying ants in her room and admits that she did not notify staff yesterday when she saw the first one. Resident stated that she has only seen a few since then. Resident stated the flying ants bit her. Asked resident if she saw them bite her and resident responded, no, but I know it's what bit me. Resident goes outside and sits almost every day. Searched room and found 3 flying ants on the wall under the light. Collected flying ants and put them in a specimen cup for the maintenance man. Informed resident that at this time she is unable to go back into her room until further notice. Notified administrator, ADON, and maintenance man (and gave him the specimen container with the ants) (Sic) LVN D During an interview on 8/4/17 at 8:18 a.m., Resident #10 confirmed she was bitten by ants in her room on the 500 hall. She confirmed she saw a lot of ants in her bathroom and room. She was unable to known an exact number, but confirmed there were at least 20+ ants. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident(NAME)had been attacked on 7/17/17 also. She confirmed she was not notified immediately by the charge nurse. She confirmed administration should have been notified immediately of the ant attacks, she stated, that's a reportable incident. The nurse should have notified someone. I disciplined her because she did not report the incident. She confirmed the physician and family should have also been notified immediately. She denied knowledge that the physician and family had not been notified until several hours later by the day shift. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing ADM 2's employment file on 11/4/17 at 9:50 a.m., revealed her date of hire as 11/14/17). While reviewing the Orkin website at https://www.orkin.com/ants/carpenter-ant/carpenter-ant-bites/, it stated: When their nests are disturbed, carpenter ants bite in defense. Due to their large size, the bite can be painful and potentially break the skin.(NAME)ants also spray a defensive chemical of formic acid, which they can spray into the bite wound, further increasing the pain. They use this ability to fight other insects and ant species when threatened. While reviewing the Cambridge University Botanic Garden website at http://www.botanic.cam.ac.uk/Botanic/TrailPlace.aspx?p=27&ix=261&pid=0&prcid=0&ppid=0, it stated: Formic acid is found in bee, wasp and ant stings. While reviewing the facility's policy for Abuse-Reportable Events, dated 7/17, it stated: Policy It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law an incident/event in which there is a cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect cause by another person. Definitions Neglect: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. 4. Identification: c. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .immediately to their supervisor or Senior Staff Member. The Senior Staff Member is defined as the highest ranking person in the building at the time of the incident. -Administrator -Director of Nurses -Assistant Director of nurses -Charge Nurse d. The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call. While reviewing the facility's policy for Incident/Accident Reporting, dated 7/17, it stated: Policy To ensure that any resident who has an accident/incident will have an investigation completed in an attempt to prevent additional occurrences. Procedure- The Charge Nurse will: -The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or there is a complaint of abuse or neglect. -Notify the physician and document the notification in the medical record. -Notify the responsible party via telephone and document the notification. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on observation, interview and record review; it was determined the facility failed to immediately consult with the Resident's physician and notify the Resident's representative when there was an accident involving the Resident that results in an injury and has the potential for requiring physician intervention for 1 of 10 residents reviewed for notification of changes (Resident #1). Resident #1 was attacked by ants on two seperate occasions: Resident #1 was attacked by ants on 7/17/17 at 2:59 a.m. The Resident's physician was not notified until 10:30 a.m., and the Resident's Representative was not notified until 10:45 a.m. This failure lead to delayed treatment of [REDACTED]. Resident #1 was attacked by ants on 7/18/17 at 3:04 a.m. The Resident's physician was not notified until 6:55 a.m., and the Resident's Representative was not notified until 6:55 a.m. This failure lead to delayed treatment of [REDACTED]. The facility's failure to immediately consult with the Resident's physician and notify the Resident's representative when there was an accident involving the Resident that results in an injury and has the potential for requiring physician intervention could place 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers at risk for a delay in treatment, lack of medical treatment, improper medical treatment, causing pain, infection, [MEDICATION NAME], shock and death. Findings include: Record review of Resident #1's clinical record revealed: Resident #1 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has Impaired vision and communication; BIMS-not completed, but further sections indicate moderate impaired; Depression-3; extensive 2 person assist for all bed mobility and transfers; total 2 person assist for dressing, toileting, ADLs, bathing and hygiene; wheelchair; no upper extremity or lower extremity impairment; always incontinent of bowel and bladder; occasional complaints of pain requiring medication; and at risk for falls and pressure sores. While reviewing the care plan for Resident #1, dated 5/25/17, it states: Chair fast, contractures, paresis, poor appetite, impaired cognition and communication, pain, ADL deficit requiring 1-2 person assist, depression, bowel and bladder incontinence, at risk for falls, weight loss and pressure sores. While reviewing the nursing notes for 7/17/17 and 7/18/17 for Resident #1, it stated: 7/17/17 at 2:59 a.m.: CNA reported finding ants in resident's bed (room [ROOM NUMBER]), took resident to shower to make sure no ants on her and then took her to room [ROOM NUMBER] to sleep for the night, placed note on 24 hour report to have maintenance treat for ants, will continue to monitor. (Sic) - LVN A 7/17/17 at 9:57 a.m.: resident remained in room [ROOM NUMBER] medications and meal given in 408, a.m. care given and resident returned to room [ROOM NUMBER] will continue to monitor t-97.2 extra water given and accepted. (Sic)- LVN B 7/17/17 at 1:36 p.m.: called to room by (CNA) observed bilateral legs and around neck, noted redden rash area Resident stated that it itches [MEDICATION NAME] ordered TID until healed. Daughter notified of ants and rash on bilateral legs.(Sic) - LVN B 7/18/17 at 3:04 a.m.: CNA reported finding ants in resident's bed, resident taken to shower to ensure ants are removed, and then taken to room [ROOM NUMBER]B for the night, will continue to monitor. (Sic) - LVN A 7/18/17 at 6:55 a.m.: Called to look at Resident due to ant bites. Multiple ant bites over bilateral legs, arms, torso, back. [MEDICATION NAME] cream was applied per charge nurse. Areas are pustule type with redness. Notified Dr. and requested Solu [MEDICATION NAME] dose for inflammation, pending return call. Notified Daughter of multiple bites and request sent to Doctor. She stated thank you for calling and I'm on my way up there. (Sic) - WCN C 7/18/17 at 7:38 a.m.: Resident's ant bites have decreased in surface area since application of [MEDICATION NAME] cream. Areas cover approximately 75% of body. Torso, bilateral lower legs and back. Variations of size Some are pustules type areas, some are superficial type areas. Sizes range from pinpoint to 0.5cm in size. Resident voices no pain. All are red in color. (Sic) WCN C 7/18/17 at 7:57 a.m.: Was notified this AM during shift change report (@ about 6:05 a.m.) that Resident has been moved to hall 500, into room [ROOM NUMBER] bed B due to during the night when CNA went to provide care she noticed ants in the bed and ant bites on the Resident. Per report, Resident was transferred out of bed and received a shower, then transferred into the bed on hall 500 Skin nurse made aware and contacted daughter and Doctor to update them on Resident's condition .Daughter stated that she wanted to take Resident to CareNow .Daughter left with Resident at 7:50 a.m. Notified DON and ADON. (Sic) - LVN D Record review of the incident report, dated 7/18/17, for Resident #1 revealed, the Resident's physician was not notified until 7/17/17 at 10:30 a.m., and the Resident's Representative was not notified until 7/17/17 at 10:45 a.m. During an observation on 11/2/17 at 1:00 p.m., Resident #1 had extensive (too numerous to count) scars to both ankles. The scarring was circumferential (completely encircling the leg) and extending up her lower legs all the way up to just below her pubic area. She had scarring to both sides of her lower back approximately 6 inches vertically x 12 inches laterally. The scarring varied in size of approximately 2-7 mm in diameter. During a simultaneous interview, Resident #1 was asked if the scars were from the ant bite/stings she sustained. She shuddered, grimaced and said, yes. When she was asked why she shuddered and grimaced, she stated, hurt. When she was asked, do you hurt now, she said, no. When she was asked, if she hurt when she was bitten and stung, she shook her head up and down and said, yes. During an interview on 11/1/17 at 3:00 p.m., Resident #1 was removed from the facility once the extent of ant stings Resident #1 had sustained on 7/17/17 and 7/18/17 was discovered. During an interview on 11/2/17 at 2:42 p.m., WCN C confirmed she was informed Resident #1 was covered in ants during the night (of the 17th). She confirmed Resident #1 had been removed from her room after being showered on the early morning hours of 7/17/17. She was uncertain when the physician was notified, but she confirmed LVN A did not notify the physician. WCN C confirmed Resident #1 was covered in ants again sometime during the early morning hours of the 18th. WCN C confirmed on 7/18/17 about 7:30 a.m., she was called by LVN D to look at Resident #1's injures. WCN C confirmed she lifted Resident #1's pants leg to look at the wounds. WCN C confirmed a conservative estimate of 600 ant bites/stings, if not more. WCN C confirmed she did not remove Resident #1's pants or visualize her thighs. WCN C confirmed she felt Resident #1's thighs where she could not visualize and they were bumpy like they had hives all over them. She confirmed Resident #1 appeared to be in pain, but denied any distress. She confirmed potential complications of the bites/stings would be pain, infection, reaction and the most serious potential complication is death. When presented pictures of Resident #1's stings, she stated, when I saw her they hadn't formed pustules yet. WCN C confirmed in her nursing judgment, Resident #1 should have been seen by a doctor. When asked if Resident #1 should have been transferred immediately for emergency treatment, she stated, we have to contact the doctor to transfer a resident. When asked what occurs when a resident has an emergency like a [MEDICAL CONDITION], stroke, etc., she stated, oh, we just call 911. She did not have an answer why Resident #1 was not transferred immediately. WCN C confirmed the stings were of a higher severity than they initially appeared. She confirmed neither LVN A nor LVN D had notified the physician. WCN C confirmed she had called the doctor on 7/18/17, but by the time he called back (about 10:00 a.m., Resident #1) was already gone with her daughter. She confirmed LVN A did not notify Resident #1's family. During an interview on 11/3/17 at 8:40 a.m., DON confirmed the first time Resident #1 was attacked by ants was on 7/17/17 about 2:45 a.m. She confirmed Resident #1 was subsequently attacked on 7/18/17 about 3:00 a.m. She confirmed LVN A failed to notify the administrator on-call, the physician, and the Resident's daughter when Resident #1 was attacked by ants on 7/17/17 and 7/18/17. She confirmed she was first notified on the morning of 7/18/17 of the ant attacks sustained by Resident #1 on 7/17/17 and 7/18/17. During an interview on 11/3/17 at 1:50 p.m., CNA E confirmed she went in to Resident #1's room on 7/18/17 about 2:30 a.m. to make her rounds. Upon entering the room, she saw ants all over (Resident #1). CNA E immediately left the room and told LVN A. She told her to remove Resident #1 from the room and give her a shower. While she showered Resident #1, she noticed multiple red dots on Resident #1's chest, abdomen, legs, and arms. CNA E confirmed she notified LVN A of the wounds. During an interview on 11/3/17 at 2:45 p.m., when DON was asked how the substandard quality of care in the area of neglect occurred, she stated, from nurses not notifying the proper people .physician, family, me, maintenance, and administrator. During an interview on 11/3/17 at 3:05 p.m., ADM 1, the current administrator, confirmed he was unaware of the issue and stated, I can't speculate, I wasn't employed here. I don't know. During an interview on 11/6/17 at 8:58 a.m., ADM 2, the previous administrator, confirmed she investigated the ant attacks; however, she stated, my first day there was 7/18/17. She confirmed she was made aware of the ant attack that occurred about 3 a.m. on 7/18/17 during morning report on 7/18/17. She confirmed she was informed of a resident being bitten by ants during the night. She confirmed during the course of the investigation, she discovered Resident #1 had been attacked on 7/17/17 also. She confirmed she was not notified immediately by the charge nurse. She confirmed administration should have been notified immediately of the ant attacks, she stated, that's a reportable incident. The nurse should have notified someone. I disciplined her because she did not report the incident. She confirmed the physician and family should have also been notified immediately. She denied knowledge that the physician and family had not been notified until several hours later by the day shift. She denied knowledge of any other residents being attacked by ants, except Resident #10. She stated, if I had known any other residents were bitten, I would have reported those too. When informed of Resident #2 and Resident #8's care plan and/or nurses' notes referring to ant bites, she denied knowledge of those incidents. She stated, If I would have known, I would have disciplined those nurses also. While reviewing the facility's policy for Incident/Accident Reporting, dated 7/17, it stated: Policy To ensure that any resident who has an accident/incident will have an investigation completed in an attempt to prevent additional occurrences. Procedure- The Charge Nurse will: -The Administrator, Director of Nursing, or Department Head on Duty should be notified promptly if abuse or neglect is suspected or there is a complaint of abuse or neglect. -Notify the physician and document the notification in the medical record. -Notify the responsible party via telephone and document the notification. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 11/2/17, documented a census of 89 with 4 residents that are bedfast all or most of the time and 62 residents requiring 1-2 person assistance for transfers.

Based on interview and record review, it was determined the facility failed to provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for three (Residents #19, #20, and #12) of three residents reviewed for immediate discharge planning. Three (Resident #19, #20 and #21) of three residents, whose closed clinical records were reviewed, were inappropriately discharged directly to home. 1) Resident #19's son was notified by telephone that the facility was discharging him on 07/22/11. He was told to come to the facility immediately and pick him up. Resident #19 was discharged home with medications, some in short supply, and with no medical supplies to administer insulin, do finger sticks, or any means to check blood pressure and pulse before he was to take certain medications. The facility did not assist with alternate placement or refer Resident #19 for home health or other services. Resident #19's son was not prepared to take care of him at home and did not have the knowledge, ability, or finances to provide all of the care he needed. Four days after discharging Resident #19 to the son's home Resident #19 went into an exacerbation of [MEDICAL CONDITION] with Dyspnea and Pneumonia. 911 was called. The resident was admitted to the hospital for four days and then to the hospital's long term acute care unit. 2) Resident #20 was abruptly discharged when the resident was observed touching a resident in an inappropriate way. Resident #20 who resided at the facility with his wife, did not receive a wheelchair upon discharge, even though it was difficult for him to walk; and his family did not receive any instructions on the care of the resident. Alternate nursing facility placement was not provided, and the resident went home with his non-medical family to care for this resident who was receiving medications to treat high blood pressure, dementia, and his appetite. Resident #20 received PRN treatments for oxygen and breathing. Resident #20 ran out of his appetite stimulant, and his eating decreased. The resident was home for only a week, before the resident's daughter called 911 when the resident had difficulty in breathing. The resident was discharged to another nursing facility after an approximate stay of 3 weeks in the hospital. The resident has been distraught, depressed and lonely for his wife. 3) The facility did not assist Resident #21 or provide prior notice to the family in discharge planning preparation prior to the resident's discharge to another facility. These failures could affect the facility's 104 residents and placed them at risk for health complications and injury related to the lack of continuity of care and access to needed services due to an incomplete and uncoordinated discharge from the facility. Findings included: 1) According to the MDS assessment, dated 06/20/11, Resident #19 was a [AGE] year-old male, who was admitted on [DATE] with diagnoses, which included Heart Failure, Hypertension, [MEDICAL CONDITION] Bladder, Pneumonia, Diabetes, [MEDICAL CONDITIONS], Bronchiectasis with Acute Exacerbation, [MEDICAL CONDITION] Fibrillation, and [MEDICAL CONDITION]. The MDS assessment reflected Resident #19 had no memory problems, had good cognition and required supervision with his ADLs. Resident #19's July 2011 consolidated physicians orders reflected the following orders: -FSBS QID with Insulin subq per sliding scale; -If the FSBS < 60 call the doctor and if 400 or greater call the doctor; -Hold Insulin if the FSBS was < 110; -Check pulse and blood pressure when giving the blood pressure medication, [MEDICATION NAME]; -Hold [MEDICATION NAME], heart medication, if pulse was < 60 and call the doctor; -One nebulizer every six hours with a medication called [MEDICATION NAME] for [MEDICAL CONDITION]; and -A second nebulizer every six hours with a medication called Atrovent for shortness of breath. Review of the facility's investigation, dated 07/27/11, revealed Resident #19 had been observed on 07/22/11 at 4:30 p.m. by two CNAs rubbing the breast of a female resident, who was diagnosed with [REDACTED]. The nurse assessed the confused female resident, and she had no knowledge of the incident. On 07/22/11 at 6:00 p.m., Resident #19 was presented with an immediate discharge letter and a CNA was assigned to monitor Resident #19 one-on-one until he left the facility. No other information was included in the investigation except "Monday, July 25, 2011, we will have a facility inservice on abuse definitions and reporting procedures." The "Resident Discharge Summary," dated 07/22/11, reflected Resident #19 was discharged on [DATE] with a discharge [DIAGNOSES REDACTED]." Nothing was documented concerning where the resident was discharged to or if services were required at the location of discharge. No follow-up was documented. Resident #19's nurses notes, dated 07/22/11 at 1:30 a.m. and at 6:30 a.m., reflected "Resident cont (continues) on skilled services R/T (related to) acute bronchiectasis and rehabing." At 6:25 p.m., the notes reflected, "attempted to contact primary contact. Contacted ____ (family member) & notified her of immediate d/c from facility & circumstances leading up to this. This done after myself & admin. (Administrator) presented immediate d/c papers to Res. Res. states can't understand why this is happening but did sign papers. Res. put on 1 on 1 around the clock till d/c occurs. Offered Res. & family to assist c/ d/c if they request it." At 7:00 p.m., "____ (family member) here to assist with discharge." At 8:06 p.m., "discharged c/ all meds., concentrator & O2 tank on electric w/c c/ ____ (family member). ____ (family member) mentioned attorney to (previous) administrator and (previous) administrator gave him info his # and said to have him call (previous) administrator c/ any questions. ____ (family member) and res. left /s any problems." Resident #19's social services notes, dated 07/25/11 at 12:00 p.m., reflected, "This sw informed at 9:20 a.m. that Resident (#19) dc on Friday nite (sic) d/t an incident involving a female resident. Spoke c/ ombudsman at length concerning this incident. Ombudsman called this sw after speaking with (previous) administrator. This sw stated she would keep ombudsman informed and she (ombudsman) offered her assistance if needed." Two and a half pages of (32) medications discharged to Resident #19, dated 07/22/11 were reviewed. Most of the medications were discharged with a two week or more supply. However, only one [MEDICATION NAME] (anti-nausea), one [MEDICATION NAME] (diuretic), and one [MEDICATION NAME] XL (for high blood pressure) were provided. Review of Resident #19's entire medical record revealed there was no letter of discharge or paper work found in Resident #19's medical record reflecting the resident or family's agreement to discharge on such short notice. During a confidential interview, it was revealed the family was called by the facility administrator on a Friday afternoon to come and pick up Resident #19 and take him home due to a sexually inappropriate incident, which had allegedly occurred that day. The interviewee stated the resident's family was not prepared or knowledgeable in the care needed for the resident at home nor was the family's home handicap accessible as Resident #19 was wheelchair-bound. However, the resident and family were not given a choice in the matter. The family was told if the resident did not leave the facility that day, Resident #19 would be transferred to the local community psychiatric hospital. This frightened the family as well as Resident #19 according to the interviewee, so the family complied. Once at home Resident #19 realized the facility had not given him all his medications. Approximately 48 hours later, Resident #19 began having difficulty with his [MEDICAL CONDITION] and 911 was called. Resident #19 was transported via ambulance to the local hospital where he stayed for four days. From there, Resident #19 was transferred to the local Long-Term Acute Care hospital where he stayed for six weeks. Placement was found in another long term care facility without any assistance from the facility. Interview with CNA P on 10/27/11 at 12:19 p.m. revealed she took care of Resident #19. She stated he used oxygen and had a small tank on the back of his wheelchair. At night he used a "big mask" hooked to an oxygen machine. She stated Resident #19 could not walk and used an electric wheelchair. During an interview on 10/27/11 at 12:26 p.m., when MA Q was queried about Resident #19's medications, she stated he took multiple medications during his stay at the facility including blood pressure medication. Before taking his blood pressure medication, his blood pressure was required to be taken to determine the necessity of the medication. Other medications he took required food or juice to be given. Resident #19 also took insulin, which the nurses administered to him. MA Q stated Resident #19 was discharged home and she was sure he had home health at home to assist with these medications, because he would need it. On 10/27/11 at 2:20 p.m., the SW was interviewed about Resident #19's discharge. She stated she was not in the loop and only learned of Resident #19's discharge on Monday after it had occurred on Friday. She stated no one called her at home. She stated Resident #19 had some inappropriate behaviors in the past year but really did not have anything to speak of in his past as far as she knew. The SW stated one incident on 07/14/11 was when Resident #19 was found in another female's room and staff asked him not go into her room again. Nothing inappropriate was observed at that time. On 07/17/11, a different female resident asked that Resident #19 not go into her room. Earlier in the year, Resident #19 allegedly hit a staff member in jest. This past incident was what lead to his discharge when he was observed touching a female resident's breast. Resident #19 had been at the facility for about seven years, and these were the only behaviors she was aware of. The SW stated they should have placed him on 1:1 until placement was found when this most recent incident occurred. The previous DON told her on the following Monday she had offered to find placement for Resident #19, and the family refused. She stated as far as she knew Resident #19 was discharged with all his medications, wheelchair and oxygen. However, she was not sure if the family was knowledgeable about Resident #19's care and medications or if the family's house he was discharged to was handicapped accessible. The SW stated as far as she knew no one called to check on the resident or arranged for home health or other services to assist him at home or to check of placement in another nursing home was necessary. On 10/28/11 at 2:18 p.m., CNA R was interviewed. She stated she witnessed Resident #19 touch a female resident's breast while both residents were in the hallway a few months ago. CNA R stated she immediately separated them and reported the incident to her charge nurse. The next thing she knew, Resident #19 was being discharged . She said she had never observed Resident #19 do that before. On 10/28/11 at 2:45 p.m., LVN G stated he was the nurse who prepared Resident #19's medications for discharge. He stated he was given instructions to get them ready but no explanation was provided. No refills were provided or syringes for his insulin as far as he knew. He stated he gave instructions as well as a copy of the medication administration records and treatment administration records to the family. LVN G stated Resident #19 had daily blood sugars, which were taken by the facility nurses during his stay but no supplies were given to Resident #19 as far as he knew. He was not sure if Resident #19 had any blood sugar supplies or syringes at home. The Emergency Physician Record from the local hospital, dated 07/26/11, reflected Resident #19 was admitted to the local emergency roiagnom on [DATE] with Chronic Shortness of Breath and [MEDICAL CONDITION] with an oxygenation saturation level of 88% (normal is 95 - 100%). The clinical impressions were documented as Dyspnea, Pneumonia and [MEDICAL CONDITION] - Acute Exacerbation. His saturation oxygenation level was listed at 84%. The hospital's Discharge Summary, dated 09/01/11, reflected Resident #19 "was admitted to (local) hospital on [DATE], with admitting [DIAGNOSES REDACTED]." The report also reflected "The patient has been staying at (facility) nursing home for the last 8 years and doing fairly well with admissions once twice a year because of problems with exacerbation of [MEDICAL CONDITION]/upper respiratory infections. The patient says that last Friday the patient was asked to leave the nursing home he was at because they accused him of inappropriately touching a female resident there. This made him extremely angry and he had to go to live with his son. This caused him to become more anxious and short of breath and in the last 48 hours, this shortness of breath and cough worsened so he came to the emergency room and was admitted on ce again." Review of http://www.pulseox.info/pulseox/what2.htm on 11/02/11 revealed "...Oxygen is carried in the blood attached to hemoglobin molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. One hemoglobin molecule can carry a maximum of four molecules of oxygen, if a hemoglobin molecule is carrying three molecules of oxygen then it is carrying 3/4 or 75% of the maximum amount of oxygen it could carry. One hundred hemoglobin molecules could together carry a maximum of 400 (100 x 4) oxygen molecules, if these 100 hemoglobin molecules were carrying 380 oxygen molecules they would be carrying (380 / 400) x 100 = 95% of the maximum number of oxygen molecules that could carry and so together would be 95% saturated. Oxygen saturation is also referred to as SpO2." 2) Resident #20 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #20 scored 15 out of 15 on the Brief Interview for Mental Status, indicating he was cognitively intact, and did not have any behaviors. Resident #20 was able to walk but required supervision on and off of the unit, and used a walker and a wheelchair. The resident required extensive assistance for toilet use, and was on a mechanical soft diet. Resident #20's discharge to the community was determined to be not feasible per review of the resident's MDS assessment dated [DATE]. Interview on 10/28/11 at 9:00 a.m. with Resident #20's family member revealed the resident had lived at the facility in the same room with his family member since he was admitted to the facility. The resident's family member was asked to come to the facility and take Resident #20 home on 09/11/11. He/She was told Resident #20 had touched another female resident inappropriately. The facility did not try and find another facility for Resident #20 to go to upon discharge. The facility "didn't help at all." The resident's family member stated, "He got sick, so depressed, wouldn't eat. He said, 'Why would I do that, I have your mother.' I can't help him. I'm not a medical person. Why did they (nursing facility) do this? He's old. He's sick. He's in another nursing home now, and he's lonely and sad. I took him home Sunday night (9/11/11). I didn't want to. They made me. He ran out of his appetite medicine, and he wouldn't eat. He kept saying, 'I'm sorry, I'm sorry.' I said, 'It's okay. It's okay.' He didn't come home with a wheelchair. I had to help him walk. He was with me for about a week or more, then he went to the hospital. He was having a hard time breathing, and I called 911. He already had some dementia, but after he went to the hospital, he didn't recognize me at first. The doctor said he didn't get enough oxygen to his brain. I had one oxygen at home, but it was almost out. He's declined mentally since he left the nursing home. My mom and dad should be able to spend what little time they have left together. They're old, and they don't have a lot of time left. They (nursing facility) never contacted me about bringing him back. I wasn't told to check his blood pressure. I don't have a blood pressure cuff. I'm not medical. I don't know how to take care of him. My mom misses him so much. My dad would never hurt my family." Review of of Resident #20's emergency physician record from a local hospital, dated 09/28/11 revealed, "...This is an [AGE] year-old male with a history of asthma, dementia, and [MEDICAL CONDITION], who presents to emergency room for evaluation of change in mental status. The patient is a poor historian, so most of history was obtained from emergency room records. The patient was brought to the emergency room because the family noticed change in mental status in a.m. En route to hospital, emergency [MEDICATION NAME] nebs and Solu-[MEDICATION NAME] 125 mg IV was administered en route to hospital. The patient's respiratory status improved. Before the patient was 74%. Upon arrival to the emergency room , O2 saturation was 98% on 3 L (liters). In the emergency room , [MEDICATION NAME] 1 g (gram) IV was administered X 1... ASSESSMENT AND PLAN: Admit to telemetry. 1. Change in mental status... Urinary tract infection... hypoxic on room air. Since shortness of breath improved somewhat when emergency medical service administered IV Solu-[MEDICATION NAME] and [MEDICATION NAME], will continue this treatment... Dementia... Depression... [MEDICAL CONDITION] Hypertension...." Review of Resident #20's local hospital's discharge summary dated 10/19/11 revealed the resident was admitted to the hospital on [DATE] and discharged [DATE]. It further reflected, "...DISCHARGE Diagnoses: [REDACTED]. 2. Group B bacteremia. 3. Pneumonia. 4. Dementia. 5. [MEDICAL CONDITION]. 6. Depression. 7. Hypertension. 8. Hematuria. SUMMARY OF HOSPITAL COURSE: ____ (Resident #20) on an [AGE] year-old male with a past medical history of [REDACTED]. The patient was found to have [MEDICAL CONDITION] and he did not have any infiltrate, which was visualized. he was, however, started on antibiotics. The patient also was found to have some bacteremia, which was thought secondary to a possible pneumonia. He was treated for [REDACTED]. He ultimately had no difficulty breathing, and it was decided that he can be safely discharged to his nursing home. The patient did actually have underlying dementia and [MEDICAL CONDITION], and he was acutely confused while he was here in the hospital. He was placed on [MEDICATION NAME] and responded to this, but needed to be reoriented multiple times and it appeared to be secondary to his underlying dementia. On the time of discharge, the patient was stable. He had no fevers and no overnight events and it was decided that he could be safely discharged to the nursing home for further care based on his dementia...." Interview on 10/28/11 at 9:50 a.m. revealed when Resident #20's discharge was being discussed, the DON stated, "It was unconscionable what they (nursing facility) did." The DON revealed the nursing facility was going to try and assess Resident #20 that day and "hopefully, get him back." Interview on 10/28/11 at 10:15 a.m. with LVN B revealed she was the charge nurse on Hall 400 on the 6-2 shift on 9/11/11 at the time of Resident #20's incident. She stated the incident occurred on Hall 400, but Resident #20 lived on Hall 200. LVN B was not very familiar with Resident #20, just that he and his wife were a quiet couple. LVN B stated CNA M came to her and said she saw Resident #20 touching a female resident on the breast, then Resident #20 took the female resident's hand and placed it on Resident #20's crotch. The two residents were separated, and LVN B told the weekend supervisor, RN I. LVN B was with RN I when she called the Previous Administrator. The Previous Administrator instructed RN I to place the resident on one-on-one. Then he said, "Then we will see how we're going to discharge him today." When LVN B was asked if it was unusual for residents to inappropriately touch another resident, she revealed it was not and in those situations, staff would "separate, assess and re-direct." LVN B stated when Resident #20 was separated from the female resident, he wanted to know why they were separating him from his friend. The resident was told the female resident needed to be taken to the restroom. Resident #20 was okay with the explanation. Interview on 10/28/11 at 10:25 a.m. with CNA M (with help interpreting from CNA L), revealed she had worked at the facility for approximately 1.5 years on Halls 200 and 400, during various shifts. On 09/11/11, CNA M walked onto Hall 400 and saw Resident #20 at the end of the hall facing a female resident and touching her breast. Resident #20 then took the female resident's hand and placed it on his crotch. CNA M reported the incident to RN I. CNA M stated she had never seen Resident #20 behave that way before. Interview on 10/28/11 at 12:35 p.m. with RN I revealed she had worked as the weekend supervisor at the facility off and on for three to four years. After learning about the allegations revolving around Resident #20 on 09/11/11, she notified the previous DON and the previous Administrator. The previous Administrator instructed RN I to talk to Resident #20 and get his side of the story. RN I stated the previous Administrator "wanted an immediate discharge. That was my understanding." RN I stated she talked to Resident #20 about the alleged incident, and the resident denied the allegation. RN I was asked if there was any discharge planning provided, and she said, "I don't recall the family asking for help." RN I stated the previous DON called the family of Resident #20 and asked them to come and get the resident. RN I stated she was not familiar with the resident but he "seemed like a nice man." Interview on 10/28/11 at 12:55 p.m. with LVN G revealed he had worked at the facility for approximately a year and had worked the 2:00 p.m. to 10:00 p.m. shift for six months on Hall 200. LVN G stated he came to work on 09/11/11 and was told by RN I, that per the previous Administrator, Resident #20 "had to be discharged ." LVN G stated Resident #20 was an "overall nice person who liked to joke." Resident #20 had never exhibited any behaviors before, and LVN G was "dumbfounded" when he heard the allegations. LVN G stated Resident #20 had [MEDICAL CONDITION], and during his stay at the facility, he had to have his oxygen saturation checked, had PRN breathing treatments, and oxygen. Resident #20 used a wheelchair, but could "ambulate a few feet." When Resident #20 was discharged , LVN G gave the daughter the resident's medications and his nebulizer. The only instructions LVN G gave Resident #20 and his family was when to take the medications. Review of Resident #20's Nurse's Notes written by RN I and dated 09/11/11 revealed, "...It was reported this resident was observed inappropriately touching another female resident. cThe resident was removed from area and placed on 1:1. I (RN I) called and notified the administrator and DON of the situation... new orders received... Family notified by DON, family voiced understanding and decided to come and take resident home... I spoke with this resident and he denied having touched the female resident in an inappropriate manner and stated 'that they were only talking' ... 1545 (3:45 p.m.) Resident left with family with meds and nebulizer. Instructed to call facility if they have any questions...." Review of Resident #20's PHYSICIAN'S TELEPHONE ORDERS dated 09/11/11 without a time, revealed, "...Please send pt to hospital for psych evaluation...." An additional order dated 9/11/11 at 2:50 p.m. revealed, "...Discharge home with family per family request...." Review of Resident #20's RESIDENT DISCHARGE SUMMARY dated 09/11/11 at 3:45 p.m. revealed, "...Admitting Diagnoses: [REDACTED]. Resident was given an immediate discharge... Medications given to family... property given to resident... Prognosis: Fair Discharge Diagnoses: [REDACTED]." Review of Resident #20's October 2011 consolidated Physicians Orders revealed the following orders: Full Code; Mechanical Soft diet with thin liquids; [MEDICATION NAME] 7.5 mg tablet to be given every hour of sleep for appitite stimulant/depression; [MEDICATION NAME] 20 mg tablet to be given everyday for Depression; [MEDICATION NAME] 3.125 mg tablet to be given two times every day for Hypertension; Check blood pressure; Check pulse; [MEDICATION NAME] 10 mg tab to be given every morning for Senile Dementia with Depressive features; [MEDICATION NAME] 7.5 mg tablet to be given everyday for pain; [MEDICATION NAME] ([MEDICATION NAME] & Atrovent) unit dose of 3 ml for inhalation whenever necessary for [MEDICAL CONDITION]; Check oxygen saturation every shift whenever necessary; Change oxygen tubing and Humidifier bottle and clean filter and concentrator every week whenever necessary; Oxygen at two liters per minute by nasal cannula whenever necessary for shortness of breath. Under Certification/Re-certification it was documented, "I certify that this resident requires a continued level of care on a daily inpatient basis. These orders are certified and effective for the next 60 days...." Review of the facility's Provider Investigation Report dated 09/11/11 regarding Resident #20's alleged incident revealed, "...Alleged perpetrator put on, 1 on 1 and moved back to his room Resident was DC'd home with his family pending investigation results... Investigation Summary... Interviewed the two Nurse Aids who witnessed the incident. Each Nurse Aid clearly described the incident as written in their respective statements. Alleged perpetrator denies inappropriate touching... Provider Action Taken Post-Investigation Alleged perpetrator was issued an immediate discharge...." The report was signed by the previous Administrator and dated 09/15/11. Review of http://www.medterms.com/script/main/art.asp?articlekey= on 11/02/11 revealed, "...Cachexia: Physical wasting with loss of weight and muscle mass caused by disease. Patients with [MEDICAL CONDITION], AIDS, and some other major chronic progressive diseases may appear cachectic. Cachexia is a wasting syndrome that causes weakness and a loss of weight, fat, and muscle. Anorexia (lack of appetite) and cachexia often occur together. Cachexia can occur in people who are eating enough, but who cannot absorb the nutrients. Cachexia is not the same as starvation. A healthy person's body can adjust to starvation by slowing down its use of nutrients, but in cachectic patients, the body does not make this adjustment...." 3) Review of Resident #21's closed clinical record revealed she was a [AGE] year-old female, who was admitted on [DATE] with [DIAGNOSES REDACTED]. Discharge plans on the MDS assessment reflected Resident #21's discharge to the community was determined not to be feasible. Interview on 10/27/11 at 11:15 a.m. with the SW revealed, "I believe the (previous) Administrator said we would take her on a trial basis. I don't remember if I was involved in that discussion." The surveyor queried the SW if MD T was informed of Resident #21's plan for discharge prior to the discharge date , and she responded, "I don't know." The SW stated, "I thought I had spoken with ____ (Resident #21's) family member about the discharge, but the family member was aware of the need for another facility." Interview on 10/27/11 at 2:50 p.m. with LVN F revealed, she did not know Resident #21 was going to be discharged on 09/07/11 until she was told by the previous Administrator to get the order for discharge. LVN F stated, "I called the Nurse Practitioner and told her Resident #21 was being discharged , and she said, 'Oh yeah. Why? OK,' and gave me the order." During a confidential interview, it was revealed Resident #21's family member received a call from the previous administrator on Monday, 09/05/11. The interviewee stated the previous administrator stated, "He wanted her (Resident #21) discharged as soon as possible." The interviewee stated, "____ (Resident #21's family member) was really upset and "____ (Resident #21's family member) told him "____ (Resident #21's family member) would move her on Thursday. They (the nurses) were not ready when ____ (Resident #21's family member) got there and ____ (Resident #21's family member) had to wait an hour because the nurse did not know about the discharge." The interviewee was queried by surveyor about Resident #21's reason for discharge and he/she stated, "They say she has [MEDICAL CONDITION] and behaves like a little kid. The nurse says she goes into other rooms and takes things and she doesn't know how to keep up with her own stuff." The surveyor queried the interviewee if there were any medical supplies Resident #21 needed upon discharge and did the facility offer any assistance if supplies were needed. The interviewee stated, "Just the medicines. ____ (Resident #21's family member) brought in the wheelchair when ____ (Resident #21's family members) came here." The surveyor queried the interviewee if the facility helped the family find placement for Resident #21. The interviewee stated, "They gave ____ (Resident #21's family member) the name of a facility but it was full and they had a waiting list. The (previous) Administrator even told ____ (Resident #21's family member) may have to take her home with ____ (Resident #21's family member)." During an interview on 10/28/11 at 2:15 p.m. with the Nurse Practitioner, the Nurse Practitioner revealed she was not aware of Resident #21's discharge prior to receiving the call on 09/07/11 from LVN F requesting discharge orders. Review of Resident #21's telephone order written by LVN F and dated 09/07/11 revealed, "May discharge to another facility with meds." The Nurse Practitioner signed the telephone orders on 09/09/11. Resident #21's "Resident Discharge Summary" signed on 09/09/11 by MD T reflected no discharge diagnosis. 4) Review of facility's current "Nursing Policy and Procedure Discharge/Transfer of the Resident." effective January 2008 revealed, "It is the policy of this facility that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical record. ...Procedure 1. The attending physician is required to write a discharge order. Verbal telephone orders are acceptable. Resident and responsible party will be notified of discharge or transfer and reason... 3. When calling the attending physician for a discharge order, inquire whether the resident's medication is to be sent with the resident. Clarify if narcotics or hypnotics are to be included. 4. If medications are to be included, write this into the order... 5. If medications are to be given to resident or responsible party, fill out medication release form. Count all medications and list all medications to be sent with the resident. Review all medication labels for accuracy; note any changes in medication instructions on medication release form. 6. Place the medication release form in the medical record. 7. Document date, time, type of transportation and individual accompanying resident. Include whether resident took medication and validation that resident/family understand instruction, complete skin assessment and mental status of resident